Paying Back Long Term DisabilityAttorneys Dell & Schaefer 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Last Name and First Name in the designated fields at the top of the form.
3. Fill in your Group Number and Insurance ID, which can be found on your insurance card.
4. In the Accident/Injury Questionnaire section, indicate whether your treatment is related to an injury/accident by selecting 'Yes' or 'No'. If 'Yes', provide the Date of Injury/Accident in MM/DD/YYYY format and specify the affected Body Part.
5. Describe the details of the injury/accident, including how and where it occurred. If a Third Party is responsible, provide their name and insurance information.
6. Answer whether the injury/accident is work-related or a result of a motor vehicle accident. If applicable, include necessary documentation such as a Police Report or letters from insurance companies.
7. Indicate if the injury is sports-related and specify the type of sport if applicable.
8. Sign and date the form at the bottom before submitting it to the provided address or fax number.

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