EE Submit Claims Prototype V2 – Wellfleet

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- Step 1 of 3

Type of Claim

Who is this claim for?

Myself
Family

Are you filing this claim for yourself or a family member?

Claimant Name *

First

Last

Date of Birth

Your Phone Number

In case we need additional information, please tell us your preferred phone number.

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

Health Screening Claim - Event Details

Date of Health Screening

When did you receive your health screening?

Name of Screening Exam

What type of health screening test did you have?

Location of Exam

Please tell us the doctor who performed the test or the facility where you received the exam.

Phone Number of Doctor or Facility

Please tell us the phone number for the doctor or facility.

Accident Claim - Event Details

Accident Date

Please tell us when the accident took place.

Accident Location

Please tell us where the accident took place. Eg. "School, Work, Home, Gym".

Is Your Condition Work-Related?

Yes
No

Has a Worker's Compensation Claim Been Filed?

Yes
No

Condition of Body Part Affected

Please detail the condition of the body part affected.