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

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

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CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file your claim, or if you
would like to appeal any determination, please contact our Customer Care Center at
1-866-541-5794, 8:00 A.M. to 8:00 P.M. Eastern Standard Time
The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
INSTRUCTIONS FOR FILING WELLNESS CLAIMS
To avoid delays in processing please fill out the sections which apply to your specific claim.
Include your policy number(s). To obtain your policy number(s) call 1-866-541-5794.
You may fax your claim to us at 1-866-427-3623. Please be assured that your claim will receive our immediate
attention. If you would like to receive your claim proceeds even faster, Allstate Benefits can automatically deposit
them into your bank account by completing and returning our ACH form (ABJ16661NY).
Please contact our
Customer Care Center to obtain a copy of our ACH form.
Allstate Life Insurance Company of New York
You may mail your claim to:
Allstate Benefits Service Center
P.O. Box 331429
Atlantic Beach, Florida 32233
POLICYHOLDER
1. First Name:
Middle:
Last Name:
E-mail:
Policy Number:
Social Security Number:
Date of Birth:
/
/
Male
Female
MO/DAY/YR
2. Home Number: (
)
Avg. Monthly Earnings:
PATIENT’S INFORMATION
3. Name: First:
Middle:
Last:
4. Date of Birth:
/
/
Age:
Social Security Number:
Male
Female
MO/DAY/YR
5. This person is your:
(ex: self, wife, son, etc.)
WELLNESS EXAM
INSTRUCTIONS FOR FILING WELLNESS CLAIMS:
Please attach the physician, clinic, or facility receipt showing the specific wellness exam performed and date it
was provided. Thank You.
ABJ10367NY-5
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Allstate Life Insurance Company of New York (Home Office: Hauppauge, NY)
PO Box 331429 Atlantic Beach, Florida 32233 Phone 1-866-541-5794
CLAIM FORM AND INSTRUCTIONS
If you have any questions regarding benefits available, or how to file your claim, or if you
would like to appeal any determination, please contact our Customer Care Center at
1-866-541-5794, 8:00 A.M. to 8:00 P.M. Eastern Standard Time
The furnishing of this form, or its acceptance by the Company as proof, must not be construed as an admission of any
liability on the part of the Company, nor a waiver of any of the conditions of the insurance contract.
INSTRUCTIONS FOR FILING WELLNESS CLAIMS
To avoid delays in processing please fill out the sections which apply to your specific claim.
Include your policy number(s). To obtain your policy number(s) call 1-866-541-5794.
You may fax your claim to us at 1-866-427-3623. Please be assured that your claim will receive our immediate
attention. If you would like to receive your claim proceeds even faster, Allstate Benefits can automatically deposit
them into your bank account by completing and returning our ACH form (ABJ16661NY).
Please contact our
Customer Care Center to obtain a copy of our ACH form.
Allstate Life Insurance Company of New York
You may mail your claim to:
Allstate Benefits Service Center
P.O. Box 331429
Atlantic Beach, Florida 32233
POLICYHOLDER
1. First Name:
Middle:
Last Name:
E-mail:
Policy Number:
Social Security Number:
Date of Birth:
/
/
Male
Female
MO/DAY/YR
2. Home Number: (
)
Avg. Monthly Earnings:
PATIENT’S INFORMATION
3. Name: First:
Middle:
Last:
4. Date of Birth:
/
/
Age:
Social Security Number:
Male
Female
MO/DAY/YR
5. This person is your:
(ex: self, wife, son, etc.)
WELLNESS EXAM
INSTRUCTIONS FOR FILING WELLNESS CLAIMS:
Please attach the physician, clinic, or facility receipt showing the specific wellness exam performed and date it
was provided. Thank You.
ABJ10367NY-5
1 of 2
(5/15)
Allstate Life Insurance Company of New York (Home Office: Hauppauge, NY)
PO Box 331429 Atlantic Beach, Florida 32233 Phone 1-866-541-5794
Important: Please sign below to acknowledge understanding of the fraud warning statement and authorization
to provide information needed for prompt processing of your claim.
I authorize any physician, medical practitioner, hospital, clinic or other medical facility, Pharmacy Benefit Managers, insurance company, the Medical
Information Bureau or other organization, institution or person, that has records or knowledge of me or my health including my prescription medication
history to give to Allstate Life Insurance Company of New York (ALICNY) its subsidiaries or its reinsurers any information relating to my claim. I also
authorize ALICNY, or its reinsurers, to make a brief report of my health information to MIB, Inc. I understand that there is a possibility of redisclosure of
any information disclosed pursuant to this authorization and that information, once disclosed, may no longer be protected by federal rules governing
privacy and confidentiality, but may still be protected by state laws. A copy of this authorization is as valid as the original. This authorization applies to
any dependent on whom a claim is filed. This authorization is valid for a period of 24 months from the date signed. I understand that I may revoke this
authorization at any time by notifying ALICNY in writing of my desire to do so. I or my representative may receive a copy of this authorization by
supplying policy number(s) and Insured’s name in a written request to the company. (In MAINE – I understand that revocation of this authorization may
be a basis for denying insurance benefits. Failure to sign an authorization statement may impair the ability of a regulated insurance agency to evaluate
claims and may be a basis for denying a claim for benefits.)
NOTICE IN NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
Sign here _______________________________________________ Date:_______________________
Check here if address is new
Claimant
Mailing Address:
City:
State:
Zip:
Telephone No:. (
)
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