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MEDICAL CLAIM FORM ELECTRICAL WELFARE TRUST FUND - page 2 / 2

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PART D

If the patient’s visit to a doctor, emergency room, urgent care center or other facility is the result of an accident or sudden illness, please provide the following information.

Date of Injury/Accident/Onset:

Was a Police Report Filed:

YES (attach copy of report)

NO

Location of the Accident or Where the Injury Occurred (provide complete address)

Describe the accident fully or how the injury occurred (attach a separate sheet of paper if necessary)

List any other individuals involved:

Name of their insurance co.

Insurance Co. Telephone No.

Name & Address of your Insurance Company:

Will medical expenses be provided by anyone (an insurance company or individual) other than you?

NO

YES – List Names

______________________________________

______________________________________

______________________________________

NOTE: No benefits are payable for work-related injuries or illnesses or for injuries that are caused by a third party such as another motorist.

The rules of this plan provide that the responsible third party, or the injured person’s private insurance, such as homeowners or motor vehicle insurance, be primarily responsible for payment for medical expenses and lost time. This plan will “advance” or “loan” benefits to pay bills as they come in. Any “advances” or “loan” of benefits are to be repaid to EWTF once the third party, whether an individual, employer, or insurance company has made payment. To secure such repayment, EWTF requires that the individual and their attorney, if any, sign a promissory note and repayment agreement before benefits are advanced.

I hereby certify that these statements are complete and true.

Signature ______________________________________________________________________

Date

______________________

Notarization is required ONLY for motor vehicle accidents and Workers Compensation.

County of:

______________________________________________

State of:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

On this

__________

day of

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ , p e r s o n a l l y a p p e a r e d b e f o r e m e

___________________________________________ , who, being duly sworn, subscribed to the foregoing in my presence.

Notary Public

_______________________________________

seal

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