Hospital confinement indemnity (gap) claim form - Assurant ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by completing the 'Statement of Insured' section. Fill in your name, policy number, address, and date of birth accurately.
3. Indicate the relationship to the insured and provide details about the patient, including their name and date of birth.
4. Describe the injury or sickness thoroughly, including how the accident occurred if applicable. Specify the date of injury or onset of sickness.
5. List the name and address of the physician who first treated this condition along with the date they were first treated.
6. Answer whether the injury or sickness is work-related and if you will file for workers’ compensation.
7. Sign and date the form at the bottom to certify that all information provided is true and correct.
8. Attach a copy of your Explanation of Benefits (EOB) and itemized bills before submitting via mail, fax, or email as instructed.

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