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Click ‘Get Form’ to open the ILWU-PMA COASTWISE INDEMNITY PLAN Medicare Supplemental in the editor.
Begin by filling out the Identification section. Enter your name, date of birth, local number, and registration number. If applicable, include your spouse’s name.
In the Explanation section, ensure you have the Medicare notice(s) ready as they must accompany your claim. Complete Part 1 and sign the Authorization in Part 10.
Answer questions regarding other insurance coverage and any accidents related to employment. Provide necessary details such as policy numbers and addresses if applicable.
Sign and date the form where indicated. If you wish for payments to be made directly to a provider, complete and sign the Optional Assignment in Part 11.
Finally, follow the filing instructions: mail your completed form along with any required documents to the ILWU-PMA COASTWISE CLAIMS OFFICE.

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Versions	Form popularity	Fillable & printable
2020	4.7 Satisfied (38 Votes)
2013	4 Satisfied (41 Votes)

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ILWU-PMA COASTWISE INDEMNITY PLAN Medicare Supplemental 2026

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ilwu pma coastwise claims mailing address

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