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- Click ‘Get Form’ to open the 7661 Tel 402 in the editor.
- Begin with the Employee’s Statement. Fill in all applicable fields, including your full name, employer, and group policy number. If a question does not apply, write 'NA' to indicate it was not overlooked.
- For the section about the Patient, select who the patient is (yourself, spouse, child, etc.) and provide their details as required.
- In the Accident section, describe the accident's location and date. Include details about injuries and any relevant reports attached.
- Complete additional benefits claimed by attaching necessary receipts or documentation for lodging or transportation benefits.
- Sign and date your statement at the bottom of the form before submitting it through our platform.
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See more 7661 Tel 402 versions
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2016 | 4.8 Satisfied (128 Votes) |
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