Assurity Wellness Screening Form

Assurity Wellness Screening Form
Wellness Benefit

Pays $50 once per day, up to two times per insured per calendar year, subject to a maximum of four times for all insured persons per calendar year, for the following screenings or exams:

● Blood screening for triglycerides, cholesterol, HDL, LDL or fasting blood glucose
● Annual physical exam
● Routine eye exam
● Immunization

Simply fill out this form and this system will email your claim form DIRECTLY to Assurity Claims. The check usually hits the mail within a couple of days!
Policyowner's Name*

First NameLast Name
Policy/Certificate #*
Policyowner's SSN*
Policyowner's Date of Birth*

MonthDayYear
Date
Policyowner's Gender*

MaleFemale
Policyowner's Phone Number*

Area CodePhone Number
Policyowner's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CLAIMANT'S INFORMATION

The Claimant is the covered person that received service for the wellness claim.
Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Relationship to policyowner*
ie: Self, Spouse, Child

Name of Medical Provider*
Medical Provider Phone Number*

Area CodePhone Number
Medical Provider Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please indicate what eligible test(s)/ procedures were performed.*

Annual Physical ExamRoutine Eye/Vision ExamBlood screening for triglycerides, cholesterol, HDL, LDL or fasting blood glucoseImmunizations
Date test(s)/ procedures were performed*

MonthDayYear
Date
Amount Charged*
Today's Date*

MonthDayYear
Date
Name of the person filling out this form*

First NameLast Name
Signature*

Clear
Should be Empty: