Section 1 – Requester's Information
Section 2 – Policy Information
Section 3 – Provider’s Information
Important: All provider information in this section must reflect the provider's employment with the insured listed in Section 2 (policy holder). Do not include details related to the provider's current or new employer.
Section 4 – Supporting Documentation
Signed Release: Needed for all requests. Release must be signed by provider within the last 90 days.
Allowed file types:.doc .docx .pdf .jpg .jpeg .gif .bmp .png .tif .rar .zip .xls .xlsx .eml
File size:Limited to 5 MB per file. Maximum files: 15. Total file size is limited to 25 MB.
Confirmation of Employment Letter. The applicant must obtain, in writing, from their (previous) employer's HR department (our insured) confirmation of employment including, policy number, status of employment, job title, and dates of employment. All responses must be on the employer's letterhead or from the employer's company email address. DOI is not an acceptable form of confirmation of employment.
Allowed file types:.doc .docx .pdf .jpg .jpeg .gif .bmp .png .tif .rar .zip .xls .xlsx .eml
File size:Limited to 5 MB per file. Maximum files: 15. Total file size is limited to 25 MB.