Z6240 Prudential Form R0414.doc 2026

1. Click ‘Get Form’ to open the Z6240 Prudential Form R0414 in the editor.
2. Begin with Section A: Insured Information. Fill in your name, policy number, date of birth, and gender clearly. Ensure all details are accurate.
3. Proceed to Section B: Patient Information. Enter the patient's name, relationship to the insured, phone number, and address. Check the appropriate patient status options.
4. In Section C: Claim Information, indicate if the patient's condition is related to employment or an accident by selecting 'Yes' or 'No'. If applicable, provide dates of accidents.
5. Complete Section D: Authorization for Release of Information by signing and dating where indicated. This allows Prudential to process your claim effectively.
6. In Section E: Authorization of Payment, decide whether payment should go directly to the provider or yourself and sign accordingly.
7. Follow Section F's instructions for submitting claims by attaching original bills and receipts. Ensure all documents are legible and submitted within 12 months.
8. Finally, review Section G: Certification of Statement. Read through the fraud notice carefully before signing and dating this section.

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