General Question

Name: First, Last:
Employer:
Member ID:
Phone:
Email:
Question:

Member ID Card Request

Full Name: First, Last:
Employer:
Inquiry Type:
Member ID:
Phone:
Email:
Question:

Member Third Party Liability Information

Member Third Party Liability Information:

If you received a request from UMR for Third Party Liability Information please complete the form below. By completing this form a determination can be made as to whether CEBT or some other entity is the primary payor responsible for claims that have been submitted.

Member Name: First, Last:
Email:
Member ID:
Patient Name:
Services Provided By:
Date of Service:
Total Charge Amount:
Was Claim Due to Injury?

Yes

No
Injury/Illness Description:
First Date of Treatment:
Date of Injury:
How Did The Injury Happen:
Place of Injury:
Was Injury at Work:
Do You Expect Further Treatment:
Is This Causing Aggravation at Work:
Has Employer Been Notified:
Is Injury From Motor Vehicle Accident:
Was Vehicle Covered By Insurance:
Other Party Name:
Other Party Address:
Other Party Phone:
Claim Number:
Policy Number:
Was Accident Reported to Law Enforcement:
Name of Agency:
Agency Address:
Has Attorney Been Retained:
Home Phone:
Work Phone:
Electronic Signature:

Member's Dependent(s) Other Insurance Information

Member’s Dependent(s) Other Insurance Information:

If you received a request from UMR requesting Dependent(s) Other Insurance Information please complete the form below. By submitting this information a determination can be made as to which coverage is primary for your dependents if they have multiple coverages.

Do any dependents have any other coverage for medical, dental, or vision:

Yes, my dependents have other insurance coverage.

Employee Name:
Email:
Member ID:
Daytime Phone:
Medical:

Dental:

Vision:
Name of Other Insurance:
Policyholder Name:
Policyholder Date of Birth:
Other Plan Eff Date:
Full Name Dependent(s) Covered:
Relationship to Policyholder:
Policy or Group Number:
Employee Actively At Work:
Is There a Court Order?

Yes

No
Insurance Company Phone:
Is Other Coverage Provided by Medicare?

Yes

No
Part A Eff Date:
Part B Eff Date:
Electronic Signature:

Employer Supply Request

Please complete the form below and we will get the requested supplies to you as soon as possible. Thank you.

Group Name:
Branch Number:
Caller Name:
Email:
Enrollment/Change Cards Qty:
Enrollment Packets Qty:
Medical Claim Forms Qty:
Dental Claim Forms Qty:
Vision Claim Forms Qty:
COBRA Forms Qty:
Rx Mail Order Forms Qty:
PPO Directories Qty:
SDA LDT/SDT Claim Forms Qty:
SDA LDT/SDT Certs Qty:
Standard Voluntary Life Booklets:
Other:

Contact

Contact Us

Request a Quote

Request a Quote

General Question

General Question

Member ID Card Request

Member ID Card Request

Member Third Party Liability Information

Member Third Party Liability Information:

Member's Dependent(s) Other Insurance Information

Member’s Dependent(s) Other Insurance Information:

Do any dependents have any other coverage for medical, dental, or vision:

Employer Supply Request

Employer Supply Request