1125a certificate eligibility form 2026

1. Click ‘Get Form’ to open the 1125a certificate eligibility form in the editor.
2. Begin by entering the 'Name of Injured' section. Fill in the last name, first name, and middle initial of the injured recipient.
3. Complete the 'Address' field with the recipient's current address. This information is crucial for identification purposes.
4. In the 'Case Name' section, provide the name associated with the case in HAWI, followed by entering the recipient’s HAWI ID number and case number.
5. Fill out personal details such as 'SSN', 'Date of Birth', and 'Sex'. Ensure accuracy as these are vital for processing.
6. Indicate the 'Date of Accident' and 'Application Date' using MM/DD/YY format. This helps establish timelines for assistance.
7. Mark the type of accident with an ‘x’ in the appropriate box and provide a detailed description of how it occurred in the designated area.
8. List all medical coverage details, including any other health insurance providers, ensuring you check all applicable boxes.
9. Finally, review all sections for completeness before saving your work. Utilize our platform’s features to sign and distribute your completed form easily.

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