Request for Reimbursement Specific Excess

Request for Reimbursement - Specific Excess

"*" indicates required fields

Insured/Employer:*

Date of Incident:*

Claimant's First Name:*

Claimant's Last Name:*

Your Claim Number:*

Safety National Claim Number:

Reimbursement of Indemnity, Medical & Expense Payments Total Amount

Indemnity Paid to Date*

Medical Paid to Date*

Allocated Expenses Paid to Date:*

Total Gross Amount Paid to Date:

Minus SIF/Subrogation/Other:*

Minus Penalties/Interest/Other Exclusions:*

Total Net Amount Paid to Date:*

Minus Self-Insured Retention:*

Amount Paid in Excess of Self-Insured Retention:*

Minus Prior Safety Reimbursements:*

Total Indemnity, Medical & Expenses Requested:*

Total Indemnity, Medical & Expenses Requested:

Final Reimbursement

Yes

Attach payment summary and detail printout by reserve category to process reimbursement.
Attach approved settlement documents if request covers settlement funds (one time only).

Supporting Documents

Drop files here or

Max. file size: 256 MB, Max. files: 10.

Sworn Statement in Proof of Loss

The undersigned, as the designated representative for the above Named Insured, states that the above figures are true and correct. Any statements attached hereto are made part of this instrument.

By:*

Date*

Name

First Last

Company:

Address*

Street Address Address Line 2 City State ZIP Code

Phone

Bank Information

Reimbursement Method

Bank ACH Deposit Preferred

Mail Check

Bank Name:*

Account Name:*

Bank Address*

Street Address Address Line 2 City State ZIP Code

ACH Routing Number*

Account Number:*

Company Address*

Street Address Address Line 2 City State ZIP Code

This is the address your check will be sent to.