Free Insurance Claim Forms and Templates

42
total templates

What Is an Insurance Claim?

An Insurance Claim Form is a formal written request that a policyholder submits to their insurance company (or government entity) to request coverage or compensation for a covered loss or policy event. The insurance company reviews the Insurance Claim and — if the claim is approved — issues payment to the policyholder or a verified interested party acting on the policyholder’s behalf.

Insurance Claim Forms

  1. Form CMS-1500, Health Insurance Claim Form (and Form HCFA-1500). The document was developed by the Centers for Medicare & Medicaid Services and is used by the patients with existing coverage of medical expenses. The application must be signed by a patient and a physician (or a supplier).
  2. EDD Unemployment Insurance Application. Individuals submit the correct version of Form DE 1101ID to the California Employment Development Department to file or reopen their claim for unemployment benefits.
  3. Unemployment Insurance Claim. If an individual becomes unemployed, they may file an Unemployment Claim with local authorities to receive their unemployment compensation benefits. All states have their own version of this claim form - some have are available for e-filing only.

Insurance Claim Related Forms

Documents

42

Form CMS-1500 "Health Insurance Claim Form"

Rate (4.4 / 5) 28 votes
Size: 1 MB
4 pages

Physicians and other healthcare providers and professionals may use this legal document to submit claims for medical services. Form CMS-1500 provides information about the patient and insured, their diagnosis, treatment, and insurance details.

Form UB-106-A-FF "Weekly Claim for Unemployment Insurance (Ui) Benefits" - Arizona

Rate (4.4 / 5) 163 votes
Size: 235 KB
2 pages

This is an Arizona legal document needed to verify that you were unemployed during the report week and are eligible to receive Arizona Unemployment Insurance or AZUI.

Form B-2 "Claimant Change of Address Form" - Vermont

Rate (4.4 / 5) 17 votes
Size: 86 KB
1 page

Form MODES-DUA-16 "Disaster Unemployment Assistance (Dua) Information for Filing a Claim" - Missouri

Rate (4.8 / 5) 28 votes
Size: 93 KB
1 page

DOL Form B-12 "Ui Claimant Appeal Form" - Vermont

Rate (4.4 / 5) 42 votes
Size: 11 KB
1 page

Form VEC-CW-31 "Combined Wage Claim Cancellation Request" - Virginia

Rate (4.7 / 5) 18 votes
Size: 20 KB
1 page

Form B-652 "Claimant's Waiver and Authorization to Release Information" - Colorado

Rate (4.6 / 5) 77 votes
Size: 39 KB
1 page

Form DOL-421 "Weekly Claim Form for Unemployment Insurance Desk Certification" - Georgia (United States)

Rate (4.6 / 5) 68 votes
Size: 49 KB
1 page

Form UC-275 "Request for Withdrawal of Claim" - Hawaii

Rate (4.6 / 5) 12 votes
Size: 23 KB
2 pages

Form K-BEN314 "Labor Dispute Statement - Claimant" - Kansas

Rate (4.6 / 5) 98 votes
Size: 164 KB
1 page

Form HCFA-1500 "Health Insurance Claim Form"

Rate (4.5 / 5) 21 votes
Size: 21 KB
2 pages

Form CLI001F (SN4227) "Unemployment Insurance Claim Application" - Illinois

Rate (4.6 / 5) 15 votes
Size: 1 MB
5 pages

Form BPC039L "Interstate Intercept Claimant Agreement Statement" - Illinois

Rate (4.3 / 5) 18 votes
Size: 411 KB
1 page

Form K-BEN3110 "Claimant Separation Statement" - Kansas

Rate (4.6 / 5) 56 votes
Size: 136 KB
2 pages

Form K-BEN3136 "Reasonable Assurance Statement - Claimant" - Kansas

Rate (4.3 / 5) 85 votes
Size: 187 KB
1 page

Form K-BEN3121 "Bonus Pay - Claimant" - Kansas

Rate (4.7 / 5) 48 votes
Size: 86 KB
1 page

Form K-BEN3119 "Separation Pay Statement - Claimant" - Kansas

Rate (4.4 / 5) 84 votes
Size: 211 KB
1 page

Form MODES-4607 "Claimant Request for Appeal" - Missouri

Rate (4.6 / 5) 14 votes
Size: 84 KB
1 page

Form NHES0180 "Continued Claim Form" - New Hampshire

Rate (4.3 / 5) 8 votes
Size: 75 KB
2 pages

Form NHES0402 "Pathway to Work Continued Claim Form" - New Hampshire

Rate (4.5 / 5) 23 votes
Size: 82 KB
1 page

Form 1697 "Initial Claim Form" - Oregon

Rate (4.6 / 5) 16 votes
Size: 187 KB
2 pages

Form 2544 "Weekly Claim Form - Self Employment Assistance (Sea) Program" - Oregon

Rate (4.3 / 5) 19 votes
Size: 96 KB
1 page

Form LB-0487 "Joint Low Earnings and Claim for Benefits for Partial Unemployment" - Tennessee

Rate (4.3 / 5) 61 votes
Size: 79 KB
2 pages

DWS-UI Form 680Q "Claimant Statement of Voluntary Quit" - Utah

Rate (4.8 / 5) 8 votes
Size: 197 KB
2 pages

DWS-UI Form 680T "Claimant Statement of Job Discharge" - Utah

Rate (4.8 / 5) 26 votes
Size: 304 KB
2 pages

State Form 56625 "Claimant Request for Notice by Mail" - Indiana

Rate (4.7 / 5) 16 votes
Size: 1 MB
1 page

Form SFN59872 "Claimant's Affidavit of Federal Civilian Service Wages and Reason for Separation - Ucfe" - North Dakota

Rate (4.3 / 5) 9 votes
Size: 166 KB
1 page

DWS-UI Form 615CV "Statement Regarding Claims for Benefits" - Utah

Rate (4.4 / 5) 17 votes
Size: 44 KB
1 page

DWS-UI Form 615CW "Statement Regarding Claim for Benefits - Worker's Comp" - Utah

Rate (4.5 / 5) 25 votes
Size: 75 KB
1 page

Form K-BEN3118-A "Job Refusal Statement - Claimant" - Kansas

Rate (4.6 / 5) 14 votes
Size: 189 KB
1 page

Form MODES-4640-R "Request for Reemployment Trade Adjustment Assistance Claim" - Missouri

Rate (4.5 / 5) 19 votes
Size: 1 MB
2 pages

Form NHES0180 T "Training Continued Claim Form" - New Hampshire

Rate (4.4 / 5) 24 votes
Size: 73 KB
1 page

Form 60-0221 "Affidavit and Power of Attorney for Claimant" - Iowa

Rate (4.6 / 5) 9 votes
Size: 306 KB
1 page

Form 69-0005 "Claimant Affidavit of Alternate Base Period Wage Information" - Iowa

Rate (4.9 / 5) 7 votes
Size: 1 MB
1 page

Form DFS-F2-DWC-49 "Aggregate Claims Administration Change Report" - Florida

Rate (4.3 / 5) 43 votes
Size: 53 KB
2 pages

Form ABJ10367NY-5 "Wellness Claim Form - Allstate" - Florida

Rate (4.5 / 5) 8 votes
Size: 31 KB
2 pages

"Claim Record" - New Jersey

Rate (4.7 / 5) 16 votes
Size: 105 KB
1 page

"Claimant Request for Hearing" - New York

Rate (4.8 / 5) 8 votes
Size: 29 KB
1 page

"Claimant Change of Name and Address" - South Dakota

Rate (4.3 / 5) 12 votes
Size: 104 KB
1 page

"Request for Claim Cancellation" - Virginia

Rate (4.6 / 5) 17 votes
Size: 45 KB
1 page