This application can be used to apply for Child Health Plus, Family Health Plus, Medicaid and the Family Planning Benefit Program. Unable to create an account using the register link for the claims email. The information is provided without warranty of any kind to any person or organisation. hWmo6+B?%j-6w[. Free Tools ; Leads by Industry ; Top Profiles . This method not only saves you time at the bank but also ensures you access funds quicker. The company's ticker symbol is AJG, and it is traded on the New York Stock Exchange. We Guard. This field is for validation purposes and should be left unchanged. EMC Share this information with your claims handler and send to them as soon as possible. Box 43078 Arthur J. Gallagher & Co.s transfer agent, Computershare Investor Services, sponsors and administers a direct stock purchase plan and a dividend reinvestment plan through their Computershare DSPP Program. Does Gallagher offer a dividend reinvestment program or other direct means of purchasing the company's common stock? Please note that Gallagher Bassett's Recruitment Department sets all policies related to your Referral Program. Providence RI 02940-3078 It provides the claim. I was injured in Dekalb County. Time and again. Computershare Investor Services (www.computershare.com/investor) is transfer agent, registrar and dividend disbursing agent Performance & security by Cloudflare. P;3.7|$=_Q)BZtLD GB\cg/ugQ|\!NnI9:i^ygG::~@D?oWt1K{!`68;z?+xHCY`5r/sl|>O3'0L(y19w7S'vb}B;>OZ6G-_~O012J4. Order form for a range of information about managing diabetes. Order form. 124 MA 02345 Check Number (do not Include) 234367 g digit Routing Number Account Number (1-17 digits) Customized web platform with client name, logo, custom policies, procedures and forms, message board, 24-hour network support. }4c:6Fax;b}Tf^}=m>;ukJ:PhM;=\~#e6tuh|?QC.gb]anTJJ}Jj, i C#(dhG`s-1Bcm^F zk+ouUjEKpaVC;)rnQVOvzV#W?&A8Sw#^|X%#!b)b6T8q)w{TU06 lxIfu51 Xeo0`\*[%Z5u"jHd}GZFX|dBv+){,B(VL6[a#nb /x x996K3t;N%Aof1oV*{g[ e8aX00f&`6Olh0[N:s\A`8 Am?t-=ZmL[qt,pvGk^\oN}fem9q Please make sure to choose an option from both lists. We designed GBCARE to provide our Resolution Managers and nurses and partners with tools and best-in-class resources . As the premiermultilineclaims services providerin the world we help people, companies and organisations around the globeimprove their claims experience. This law firm website and legal marketing are managed by MileMark Media. .|QH$Ac0L0Xsa4DLM.V\ *4HGYXHNcx'%! Product Liability, Product Recall, & Life Sciences. endstream endobj 5 0 obj <>/Subtype/Form/Type/XObject>>stream Cannot click on check payments, when they do show up, for detailed information on the payment. Check payments are sporatic. The app is secure, easy to use and reliable. 24/7 Emergency Care & Ambulatory Services. endstream endobj 112 0 obj <>stream endstream endobj 6 0 obj <>/Subtype/Form/Type/XObject>>stream Mail inquires can be made via US Postal Service to: Computershare Trust Company, N.A. Doctor Appointments - Track and manage your doctor appointments and receive friendly reminders on the SMARTbar. Box 43078 %PDF-1.6 % endstream endobj 107 0 obj <>stream Box 43078 /Tx BMC Insurance Claims Contacts | Gallagher USA Insurance Insurance Claims Contacts Claims From carrier contacts to claims administration, we're here for you Access insurance carrier contacts to file claims; our claims management and advocacy team and third party claim administration Commercial Lines Claims Contacts Hello Clinton, We are currently experiencing a system outage and are working diligently to restore all functionality. Gallagher Bassett We Guide. Forms and other information related to assisted living facilities and related issues in New York State. `W,M|]6]S08* sg$ q'6M9hX% 9gu sl Your IP: make it better. If the company was better I would probably rate the app higher unfortunately I don't have a choice. Its a convenient method of acquiring additional Gallagher stock through cash payments, reinvestment of dividends or both. They do it with a spirit we callOwn the Outcome. Treatment that is reasonable and required for you to recover from your injury will be funded by Gallagher Bassett, including Doctors appointments, surgeon consultations, physiotherapy and medication.It is important to note that certain treatment will require a referral and pre-approval, such as: Treatment must be provided by a WorkSafe registered provider to ensure we can reimburse you. A hard copy of the plan brochure and enrollment form can be requested at: Computershare Investor Services To identify and deliver the right resources, at the right time and in the right place. After submitting your request, you will receive an activation email to the requested email address. P.O. HW[o8~_FRnYtD[E2dmU,_2 sxws!?&t>e/LrZne}j #mQW(aclni EMC EMC The sooner. Your rights as a hospital patient in New York State. Discover the difference we can make inWorkers Compensation,General Liability,Auto Liability,Professional Liability,Medical Malpractice, andProperty. Report or manage a Victorian workers' compensation claim. Completed all the entry data and selected the checkmark. Payments - View benefit payments history, receive instant notifications when payments are issued and enroll in Direct Deposit. or investor_relations@ajg.com, Computershare Trust Company N.A. Your business and your people deserve the best service and solutions around. Orthopedic Clinics in the Metro Atlanta Area. For 60 years, we have provided specialized claims service programs to meet the unique risk management needs of organizations like yours. EMC Great news! eDcDcfS4cIP(mfrI4S!y\I+_K~{}{c+_i v The underwriter was Morgan Stanley & Co., Incorporated. EMC This application can be used to apply for Child Health Plus, Family Health Plus, Medicaid and the Family Planning Benefit Program. The issue in GetHuman3437988's own words Set up direct deposit . Chicago, IL. We apologize for the inconvenience. Privacy Policy Direct deposit only shows once they have issued it, can't see future deposits or scheduled deposits. Each one dedicated to delivering a demonstrably superior outcome. hPMk@}?eu"^JRbxGnp70_c39MyEkPowf)OSwjZMQ\{W.G0 dg3,vaM!? You hire a partner to handle your claims because, in your heart, you know theres a better way. /Tx BMC Order form for a range of information about managing diabetes. Companies respond better when others are watching. Terms of Use endstream endobj 113 0 obj <>stream Workers' compensation benefits generally cover medical costs and lost wages due to work-related injuries. Print your direct deposit form or download PDFChef by Movavi to fill it out on your computer. 2021 Gallagher Bassett Services, Inc., All Rights Reserved. EMC Box 944255 . This is a legal Agreement between you and the producers of this website. If you are a current or former employee of Gallagher Bassett, we suggest that you direct all policy-related questions to HR. Can I still go to the doctor if I get fired? /Tx BMC By providing your email address below, you are providing consent to Arthur J. Gallagher & Co. to send you the requested Investor Email Alert updates. To opt-in for investor email alerts, please enter your email address in the field below and select at least one alert option. I read through the reviews and uninstalled and reinstalled the app with the same results. Weve been answering that call every day for over 50 years. This field is for validation purposes and should be left unchanged. Just keep passing the buck. Please use for Northern Territory Claims Only Please complete the attached form if you wish to receive payments via EFT. GBGO mygbclaim app lets injured workers manage their claim anytime, anywhere from their Apple or Android smartphone. CbMQeEu79V,LiE5  and lost certificates should be directed as follows: Shareholder online inquiries can be made at https://www-us.computershare.com/investor/Contact. All rights reserved. What is Gallagher's ticker symbol and on what exchange is the common stock traded? oX^&) ^FizVgN5@&|[ lN1[Uu{lVW.`3m*BjkiQGed$ lnp+zqC?U=2n6_\UjC/f" ]r endstream endobj 12 0 obj <>/Subtype/Form/Type/XObject>>stream Box 43006 A pop up appeared for a second stating it was "creating account", then nothing but the words Object, object in red in the dialogue box above the checkmark. We recently made changes to our privacy policy - please click through to learn more about these important changes. GBGO mygbclaim GBGO mygbclaim - Taking Claims Management Mobile. Gallagher Bassett can deposit your reimbursement directly into your bank account or via cheque. Elderly Pharmaceutical Insurance Coverage (EPIC) Family Health Plus Application. Direct Dial: +1 312 764 6902 Direct Fax: +1 312 995 6330 jlambert@kslaw.com August 3, 2018 BY MAIL . of Health form for reporting communicable diseases. VP Investor Relations The NYS Dept. F`3P"g AB(eb 6 endstream endobj 108 0 obj <>stream Direct deposit is a payment method where your funds are transferred electronically to your bank account. endstream endobj 11 0 obj <>/Subtype/Form/Type/XObject>>stream ?x:(neJCkhQ)z};i"B4V"vYnx { M"h:n,fL 4h:NG %csZKmS=poxR2[3xi@{SeT/5f)V Ho~Uwq *il\7l$Vn-s^u]O^iPD)o8XPH0j^Ais6EX^A%Z{Bm6`Fmfml7mjr._\\P[lEiESN;fIP!h;gA}ySe@aQ8cQbIyy$0 L3 A program for free health care (HIV Drugs, Primary Care, Home Care, and APIC) for New York State residents with HIV infection who are uninsured or underinsured. Please fill the form to be able to download the original poster. hDj0DeOM,MCILs YQ -U~h)S6)>RpA|$#$2F$ c$(&'$ NYS Out of Network Consumer Protection Law, MOLST: Medical Orders for Life-Sustaining Treatment, Dental Health Educational Materials and Publications, Elderly Pharmaceutical Insurance Coverage, Family Planning Benefit Program Materials. 2023 Gallagher Bassett Services, Inc., All Rights Reserved. EMC Explore our global capabilities. By accessing this service, you agree that Gallagher Bassett is not liable for any expense, loss or cost you may incur as a result of the information on this site being inaccurate or incomplete in any way or incapable of achieving any purpose. Workload management system for multiple employers/locations/sites. Family Planning Benefit Program Materials. Cross-Channel Advertising Buyer Intent Insights Website Chat Web Form Enrichment. Can I get reimbursed for my mileage expenses in my workers compensation claim? Providence RI 02940-3078 Week before Christmas and I haven't received my pay. You must click the activation link in order to complete your subscription. Providence, RI 02940. endstream endobj 13 0 obj <>/Subtype/Form/Type/XObject>>stream License Agreement. If you wish to take up the direct entry option please complete the EFT form. Global Capabilities. By using this website, you are agreeing to be bound by this Agreement. P.O. A total of 1,210,000 shares were priced at $13.75 ($ 1.72 post-splits) per share. Appoint someone you trust to make health care decisions for you if you lose the ability to make decisions yourself. The terms of this Agreement govern your use of and access to this website. Phone: 630-285-3661 Taking the responsibility to make better decisions earlier in the life of every claim. endstream endobj 111 0 obj <>stream In a previous post, we mentioned that some insurance companies (though not all) will allow an injured worker to set up direct deposit of their weekly TTD checks. We guard our clients names and assets with unrivaled products and service. 106 0 obj <>stream We're a company dedicated to delivering the products and services that equip people, businesses and organizations to make the most of their futures. But also a way of delivering more to the people counting on you. h22T0P62A Tel: 312-360-5386. P.O. They were granted to shareholders of record as of March 1, 2000, and June 30, 1986, and both were two-for-one. I would have to agree with the consensus that the app, while thoughtfully conceived, was poorly executed. /Tx BMC Doesn't have all options for Dr appts or locations. Gallagher's initial public offering was on June 20, 1984. Please contact your Gallagher Bassett claims representative or call (800) 922-5246 for information on claims that happened in other states. EMC Raymond Iardella endstream endobj 110 0 obj <>stream By O'Connell Law Firm | Posted on October 28, 2020 If you choose to fill out a paper copy of . By continuing to browse this site, you give consent for cookies to be used. Download a blank direct deposit template using the button above. We guide those suffering a loss to the best outcomes for their futures. Ours is a story about leading - with a unique balance of strength and compassion. hko8c%qXptk\d{Ap`,"K^=fe6`Igpy#R !zN(a 3sI,/ ~FX0 S@9ai &A0HHqO`1peR0 PLBb )8 Y8 Cb 1`S D>1yZ&$DNa~I T~N>Y9\rfR- 1}S-,+r br[jDe57 )>2}lg7||7||Co,_)! FfR! What do workers' compensation benefits cover? Information and Forms - Gallagher Bassett NZ USA UK SGP Poster Designer Make a Claim Enquire Now Careers Blog 1800 931 035 Home > Northern Territory Government Return to Work LaunchPad > Return to Work Launchpad - Agencies > Information and Forms Information and Forms For Agencies Information and Forms For Agencies Reduced server costs-Gallagher Bassett houses all information. It's in our DNA to go beyond the . Gallagher Bassett Services corporate office is located in 13801 Riverport Dr Ste 501, Maryland . endstream endobj 8 0 obj <>/Subtype/Form/Type/XObject>>stream Second time going weeks without my pay. Click to reveal Read case study. Gallagher granted a two-for-one stock split to shareholders of record as of January 2, 2001. This one application can be used to apply for Child Health Plus, Family Health Plus, Medicaid and the Family Planning Benefit Program. Search our free database to find email addresses and direct dials for Gallagher Bassett Services employees. In consideration of your agreement to these terms and for other valuable . EMC The better. /Tx BMC Once you have done that can enter your banking information and your claim number to get direct deposit of your checks started. We use cookies on our website. Training program assignment and completion tracking. P.O. Gallagher Bassett Locations : Gallagher Bassett Global Reach Across town or across the globe, the people of Gallagher Bassett are ready to GUIDE. A way of savings, yes. There are several actions that could trigger this block including submitting a certain word or phrase, a SQL command or malformed data. If you are receiving checks from Gallagher Bassett you can set up direct deposit of your checks by downloading the GBGO app from your smartphone. 1. 155 0 obj <>stream I am trying to do direct deposit. p3h9f8! =b){v/}-%e* GMi>)B8^Xrb` 8e` Prior to that, the company had two other stock splits since its 1984 public offering. Affordable Housing Insurance and Consulting for Nonprofits, Claims Management and Third Party Administration, Compensation Consulting and Total Rewards Programs, Human Resources and Compensation Consulting Overview, Meet the Human Resource Compensation Consulting Team, Leadership Development and Organizational Consulting, Physician and Advanced Practice Provider Compensation Services, https://www-us.computershare.com/investor/Contact. How to fill out a direct deposit form. You can sign up for additional alert options at any time. We see it as the moment when we're called to do more than make good. .uK\OL|phN`%r7a#gI2hW y$W!kWU)*(H-"/ lD2/Aj2\.T2lzju(bIQp.a)\pGl <8fp`&7tzzz"p~CR/ 7z:l:#Q4;z- t[4jyu7%t~t|K)e 6Pw"Ozu}H+ZNILKzqSZNf-* b9i!p1O-tn]\U&R5o+P7bDXX-7 >86vZ$ Tu64@P0Tx#8_?JC\:cf%m+;Zm]q,6]!j]6/PB7mDr|O[ZeoeQJ6*n50dBq#hSHl1yeA7R+z]-VD5 itAjC%? ma^7CYgY{CF2QQa7tI7wz|jO Safety starts with understanding how developers collect and share your data. )+)r9Q&|$% "RL` Privacy Policy We guide our clients to improve their claims handling processes. Box 43078 Update: Direct Deposit with Gallagher Bassett. Gallagher Bassett Services Workers Compensation Vic Pty Ltd Locked Bag 3570 GPO Melbourne VIC 3001 t: (03) 9297 9000 f: (03) 9297 9010 e: wcv@gbtpa.com.au MEDICAL & LIKE EXPENSE www.gallagherbassett.com.au DIRECT ENTRY APPLICATION FORM Date: GALLAGHER BASSETT SERVICES WORKERS COMPENSATION VIC PTY LTD Locked Bag 3570 GPO Melbourne 3001 Please use for Northern Territory Claims Only, Please fill the form to be able to download the original poster. You can unsubscribe to any of the investor alerts you are subscribed to by visiting the unsubscribe section below. . Throughout the claim investigation process, you may have various . From powerful tools to manage your claims smarter, to little extras which ensure you love the service you receive, every myGB benefit is designed with you in mind. Human Resources and Compensation Consulting. Our RMs are the most engaged and empowered youll find anywhere in the business. lQL-'fY ,xiQP)/!D9D8D!q*Kp`xE1S`O88Yn1`W92>&paH9:H[L What happens now? Information about Child Health Plus insurance program. Gallagher Bassett assists over 3,500 clients worldwide through more than 110 branches and over 4,700 skilled professionals by providing: Claims management Risk management and information management systems Medical Cost Containment Consultative Services (environmental health and safety) Find out how we reduced medical costs by 19%. pG o Please try in a few hours. | Read More. Its in our DNA to go beyond the expected. Another way to make sure you are not out of pocket is to ask your medical provider or chemist to bill Gallagher Bassett directly. Ha that doesn't happen!! Please check with your provider prior to commencing treatment. Copyright Gallagher Bassett Services Pty Ltd. All rights reserved. Providence RI 02940-3078 Tel: 312-360-5386. Gallagher Bassett has an app available for free download on both iPhone and Android called "GGo". GBCARE, our medical management platform of solutions and integrated service partnerships, is engineered to provide the right level of medical management support at the right time to help injured workers on their path to recovery. (*-OKoJxBOpSo=f/X8Fz72I3s+y-5-_*O:abD@!xZID!B CPa} 9)-zB`(^bwKy(Ry6Y\]m$aD_f0C*xaPXi4 H?OvD:.{rhB2uX3` 5%8>)P=kJ*P=KMn7`xmos_$29jf8LVl9(sx({P.Q[}?I]>Jib)h}Pdjul_yrv?f>]Xi go\'N-Vn@)|`? Anxe!{ ? A new version of GBGO mygbclaim app is now available from the Google Play Store! Once you have done that can enter your banking information and your claim number to get direct deposit of your checks started. Gallagher Bassett can deposit your reimbursement directly into your bank account or via cheque. EMC . But no one seems to care. z - The company's 2022 Annual Meeting of Stockholders will be held on Tuesday, May 10, 2022, at 9:00 a.m. CST. Arthur J. Gallagher & Co.'s transfer agent, Computershare Investor Services, sponsors and administers a direct stock purchase and dividend reinvestment plan (DSPP) for Gallagher stock. Representatives are available Monday through Friday We place people right at the heart of our process. /Tx BMC The app isn't horrible but it doesn't give much info either. endstream endobj 109 0 obj <>stream We see it as the moment when were called to do more than make good. Arthur J. Gallagher & Co.'s transfer agent, Computershare Investor Services, sponsors and administers a direct stock purchase and dividend reinvestment plan (DSPP) for Gallagher stock. Want to manage your claims on your phone? We guard our clients' names and assets with unrivaled products and service. The action you just performed triggered the security solution. endstream endobj 7 0 obj <>/Subtype/Form/Type/XObject>>stream You will need . We recently made changes to our privacy policy - please click through to learn more about these important changes. When the unforeseen becomes reality, will your claims services providerrise to the challenge? h10rKbVKASpM@IV\n8{g@St c7w6n&wz03}kn\"=8^[wRl5n0\TvvGez4$hUj={RU{w. u2 You can email user support with any questions you have about the Social Sourcing product. When is Gallagher's Annual Meeting of Stockholders? The Gallagher Bassett Resolution Manager. Subject to the Board of Directors' approval, the company announces the cash dividend every quarter in a press release. Complete some details below and we'll get back to you with our professional recommendations. for Gallagher's common stock. If you need to file an insurance claim, completing a Preliminary Damage Assessment Report with pictures or video of the damage may help expedite the claims process. myGB is our suite of client benefits, designed to make sure you receive a personalised, valuable and user-friendly service. Make sure you obtain a receipt for every expense you would like to claim and submit this to your employer or Gallagher Bassett, ensuring your claim number is written on all documents. uJ\aMU|p@cto]ZRrVRVuGCRLKE)iT^U#^*( e;CaG!dW=wNMQ_zp@73EqONh'o pCS c Yes, this service is available through the company's transfer agent. At Arthur J. Gallagher & Co., we promise to treat your data with respect and will not share your information with any third party. Does Gallagher offer direct deposit of common stock dividends? A key goal for risk managers is to achieve zero lost time claims and increased closure rates within workers' compensation program. We Go Beyond. htn0_O06I@Q [=, k{hhVl]lH.MuVj\W}ucodBGI|Q(15'x"?ab8i[4* Its important that you know that we can only fund one type of physical treatment (physiotherapy, osteopathic or chiropractic) at a time. hVn:}lVj*nn4)}(IM,A.CL A8r)! Please complete the attached form if you wish to receive payments via EFT. And theyre backed by the best analytical and reporting tools available. between the hours of 8:00 am to 5:00 pm (Central Time). P#^\su'\4ZJ-U'PtF)S_{0PT)8! GUARD. 8HzIHG)9*T4U ~~P,-tt dv:tt~>=9*y+\CS.Vwf}O,EY8VWmhPY. endstream endobj 10 0 obj <>/Subtype/Form/Type/XObject>>stream Gallagher Bassett administers many workers compensation claims in Georgia. If you are receiving checks from Gallagher Bassett you can set up direct deposit of your checks by downloading the GBGO app from your smartphone. Xavier Becerra . Select an option below to view our locations both within the United States and internationally. Where will my workers compensation hearing take place? (r{9N4LqeSy+TxG~*NN/D8DtQU.F sG wWZaZ>jBV|\.I. Provider Portal. endstream endobj 4 0 obj <>/Subtype/Form/Type/XObject>>stream Please make sure to choose an option from both lists. P.O. 2021 - 2023 OConnell Law Firm. Health Care . When was Gallagher's initial public offering? Payments can only be made to a bank, building society, or credit union account held in the payees name, solely or jointly either with another person or organisation. App is not updated for Android 12 or higher. If you need further information contact your Case Manager. Sitemap, Although Gallagher Bassett Services Pty Ltd has taken all reasonable care in the preparation of the information provided on this site, Gallagher Bassett does not guarantee that the information is necessarily true, accurate or complete. Discover the people, the products and the process which make GB the industry leader. If you have any questions about the amount we will be able to reimburse, please give us a call. WELCOME TO THE WORLD OF GALLAGHER BASSETT A WORLD OF POSSIBILITIES As the premier multiline claims services provider we help people, companies and organizations around the world get back on track. endstream endobj 9 0 obj <>/Subtype/Form/Type/XObject>>stream /Tx BMC Tel: 312-360-5386, or online via the web at: http://www.computershare.com/investor, Raymond Iardella The company's fiscal year ends December 31. All requests for direct deposit should be directed to Computershare Investor Services. Filing an insurance claim. Terms of Use By accessing this service, you agree that Gallagher Bassett is not liable for any expense, loss or cost you may incur as a result of the information on this site being inaccurate or incomplete in any way or incapable of achieving any purpose. At GB, we view Claims Management as the absolute fulfillment of all the promise and potential of the entire insurance industry. ]]L5s-8'"7 2vU5J.Cf>>;Bz0zg0>zPB_i@j~1D`hO? P.O. Complete some details below and we'll get back to you with our professional recommendations. VP Investor Relations, E-mail: ray_iardella@ajg.com The information is provided without warranty of any kind to any person or organisation. License Grant. This payment method allows you to receive payment more easily and avoid dealing with physical cheques. The people we serveand a very special person who makes it all happen. %PDF-1.6 % We guide our clients to improve their claims handling processes. Information and Forms - Gallagher Bassett Home > Northern Territory Government Return to Work LaunchPad > Return to Work Launchpad - Workers > Information and Forms Information and Forms For Workers Information and Forms For Workers Visit the WorkSafe worker page for the latest forms and information and FAQs. A new version of GBGO mygbclaim app is now available from the Google Play Store! Sacramento, CA 94244-2550 . Download our mobile app GBGO mygbclaim for iPhone or Android phones My Doctor gave me work restrictions. GBGO mygbclaim helps users manage their claims anytime, anywhere from their smartphones. Re: Notice of Security Incident Affecting Gallagher Bassett Services, Inc. and its Clients Local Talent. At GB, we view Claims Management as the absolute fulfillment of all the promise and potential of the entire insurance industry. California Department of Justice . Who is Gallagher's transfer agent and how does a registered shareholder contact the agent regarding account information? To learn more, visit our benefits overview page. GO BEYOND. We are proud of our proven reputation for consistently delivering high-quality, cost-effective claims management to our clients across the globe. /Tx BMC We're called to go beyond and. 315 W. Ponce de Leon Avenue, Suite 580 Decatur, GA 30030. Information on this health insurance program designed to assist small business owners, their employees and their employees families as well as uninsured sole proprietors and workers whose employers do not provide health insurance. Please make sure you provide them with your claim number. Another way to make sure you are not out of pocket is to ask your medical provider or chemist to bill Gallagher Bassett directly. Data privacy and security practices may vary based on your use, region, and age. You can email the site owner to let them know you were blocked. Updated 05/19? https://www.gallagherbassett.com/privacy-policy/. Payee Name Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country Telephone Email Claim Number (if known) 0 of 9 max characters Case Officer Name (if known) Employer