Trustmark wellness claim form: Fill out & sign online

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01. Edit your trustmark wellness claim form online

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Click ‘Get Form’ to open the Trustmark Wellness Claim Form in the editor.
Begin with Section A, where you will enter your Policy/Certificate number, your name, and the patient's details including their date of birth and relationship to you. Ensure all fields are filled accurately.
Move to Section B and provide a detailed account of the accident, including dates and descriptions. Attach any relevant bills that support your claim.
In Section C, have your attending physician complete their statement regarding the diagnosis and treatment related to the accident. This section requires their signature.
If applicable, Section D must be filled out by your employer detailing your job title, duties, and any work-related aspects of the accident.
Finally, review all sections for completeness before signing the Disclosure Authorization at the end of the form. Make sure to keep a copy for your records.

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