Pertzborn Agency

Globe Life Family Heritage is dedicated to making your claim filing as easy as possible. This checklist is designed to guide you with filing your claim. Our claims professionals are also available to assist you through the claims process. If you need assistance, please contact us.

Before you start, you will need:

• Policy Number

• Policyholder's Name and Address

• Policyholder's Date of Birth

• Policyholder's Phone Number

 

To file a claim, you will need:

• Patient/Claimant's Name

• Patient/Claimant's Date of Birth

• Patient/Claimant's Relationship to the Policyholder

• Supporting Documents

 

Please obtain the following supporting documents if applicable to your claim:

• Accident Claim Form (download and print if mailing or faxing your claim)

• Physician's Statement completed by the physician (download and print to submit an eClaim)If you are not able to have this form completed and signed by a physician, a copy of the complete medical records (available from the medical facility) indicating the cause and treatment of the accidental injury must be submitted. Please do not send patient discharge instructions.

• Complete, itemized hospital bill listing the daily room charges (for inpatient hospitalizations) and emergency room chargesItemized hospital bill example
  UB-04 bill example

• X-ray report(s) or medical records (MRI, CT scan, etc.) diagnosing the fracture(s)

• Ambulance bill

• Operative Report (if the policy includes a Surgery Benefit)

• Itemized physical therapy bills

• Accident and police reports

• Alcohol and toxicology reports

• Applicable medical records/reports for other benefits that may apply (Dismemberment, Paralysis, Dislocation, Concussion, Coma, etc.)Please refer to your policy for specific benefits as these may vary.

• Lodging statement or invoice that includes the room charges for each day (for inpatient hospitalizations only)

• Any other itemized medical bills, medical records, or supporting documents1500 HCFA statement example

 

Accidental Death Claims also require:

• Original, certified death certificate (must be submitted by mail only)

• Autopsy report and certified copy of the coroner's report

• News articles and reports