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Statement for Miscellaneous Services F245-072-000
Claim number. Give the workers claim number. Name. Write the workers legal name in the last, first, middle initial format. Date of injury. Date of injury
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Member Submitted Claim Form PBC
Scan and send this completed form and any required documents back to us as a secure email attachment. Mail to: Premera Blue Cross. PO Box 91059. Seattle, WA
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File a Tort Claim | Department of Enterprise Services (DES)
The Washington State Tort Claim form is for use only if you believe that you were harmed by the state of Washington, its officers, employees, or volunteers.
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