INSURANCE VERIFICATION FORM

FOR HEALTH INSURANCE

FIRST & LAST NAME:

INSURANCE ID#

INSURANCE NAME

DATE OF BIRTH

CAR ACCIDENT INSURANCE

FIRST & LAST NAME:

CLAIM#

CLAIM MANAGER'S NAME & NUMBER

DATE OF ACCIDENT:

CAR INSURANCE NAME:

L&I CLAIM

FIRST & LAST NAME:

CLAIM#

CLAIM MANAGER'S NAME & NUMBER

DATE OF ACCIDENT:

CAR INSURANCE NAME:

Note: After you fill out your information, please snap a picture and text it to 253-630-6614 or fax it to 253-630-6624. Should you have questions, please text directly to 253-630-6614. Have a great bless day!