Electronic claims submission

The following third party-related information is required on the claim, in addition to the other required claim data:

Claim Form Include the Following Third Party Information                In These Claim Fields

CMS-1500 • Other Insured’s name, policy number, insurance             BLOCK 9 - 9D

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• Was condition related to (accident)                                                   BLOCK 10                           

• TPL paid dates                                                                                 BLOCK 19

• Amount paid                                                                                     BLOCK 29