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Trustmark wellness claim form 2026

The document is an Accident Claim Form from Trustmark Insurance Company, which must be completed by the policy owner, attending physician, and employer for claims related to accidents. It outlines the necessary sections to be filled out, including personal information, accident details, medical treatment information, and employer statements. The form emphasizes the importance of providing complete and accurate information to avoid delays in benefit consideration and includes fraud warnings specific to various states.

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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.

Start filling out your Trustmark Wellness Claim Form online for free today!