Part I - EMPLOYEE INFORMATION

Employee Name *
Prefix
First *
Last *
Suffix
Status *
Sex *
 Male 
 Female 
Date of Birth *

MM		/
DD		/
YYYY
Enrollee/Employee ID or SSN *
Group Name or Number *
Address *
Street Address *
Address Line 2
City *
State / Province / Region *
Postal / Zip Code *
Country *
Email Address *
For newsletter purposes only. This information will not be sold or used by LifeWell for any other means.
Newsletters?
 YES 
 NO 
Would you like to receive our email newsletter with the latest LifeWell information and tips?

Part II - COMPLETE ONLY IF CLAIM IS FOR DEPENDENT

Dependent Name
Prefix
First
Last
Suffix
Relationship
Date of Birth

MM		/
DD		/
YYYY
Sex
 Male 
 Female 

Part III - OTHER INSURANCE INFORMATION

Was your spouse (if applicable) employed at the time of treatment? *
 YES 
 NO 
 N/A 
Spouse's Employer
Spouse's Date of Birth

MM		/
DD		/
YYYY
Is the patient covered by any other medical/dental insurance? *
 YES 
 NO 
If Yes, which of the following?
 Other Employer Group 
 Automobile Policy 
 Medicare 
Other insurance provider

Part IV - ILLNESS/ACCIDENT DATA

Is this claim due to an accident? *
 YES 
 NO 
Is this claim due to an auto accident? *
 YES 
 NO 
Date of Accident/Injury

MM		/
DD		/
YYYY
Was the illness/injury work related? *
 YES 
 NO 
Accident Details
Give a brief description of the illness/injury/accident above.

Part V - AUTHORIZATION OF PAYMENT

I AUTHORIZE PAYMENT OF BENEFITS BE MADE: *
I certify that to the best of my knowledge, the information provided above is complete and true. *
 AGREE 
Upload a File
Please upload any necessary supporting documentation - such as statements, bills, reciepts, etc.

**NOTE: After you click Update Info you will be directed to our Thank You page. If you are not redirected please scroll up and make sure you have completed all required fields.
Image Verification
captcha
Please enter the text from the image:
[Refresh Image] [What's This?]