CLAIM FORM FOR MEDICAL BENEFITS
AGVA WELFARE TRUST FUND
363 Seventh Avenue ~ 17th Floor
New York, NY 10001-3904
(212) 627-4820 ~ AGVAUSA.com

PLEASE PRINT LEGIBLY AND RETURN THIS FORM WITH ORIGINAL DOCTOR BILLS* & RECEIPTS
~ALL CLAIMS MUST CONTAIN DIAGNOSIS AND PROCEDURE CODES~
DATE______________________________________

LAST NAME_____________________________________________FIRST NAME______________________________________________

STAGE NAME____________________________________________________________________________

ADDRESS____________________________________________________________________________________APT-_________________

CITY_________________________________________STATE___________________________________ZIP CODE___________________

DATE OF BIRTH (mm/dd/yyyy)________/________/_____________ SEX (circle to indicate) Female Male

SOCIAL SECURITY #___________-______-___________AGVA MEMBERSHIP # _____________________________________________

PHONE (______)__________-________________CELL(______)___________-___________________

EMAIL ADDRESS____________________________________________________________________________________________________

MOST RECENT AGVA PERFORMANCE (Group & Venue) & DATE:___________________________________________________________

OTHER HEALTH CARE INSURANCE (name of plan, address, policy & group #s)________________________________________________

____________________________________________________________________________________________________________________

WAS CONDITION RELATED TO: EMPLOYMENT- yes no AN AUTO ACCIDENT- yes no

PLEASE SIGN WHERE INDICATED BELOW:

I hereby authorize my provider to release information, as necessary, to AGVA Welfare Trust Fund in order to process this claim.
I hereby certify that the above statements are complete and accurate to the best of my knowledge. I also agree to reimburse The AGVA Welfare Trust Fund to the extent of any overpayment which is in excess of the amounts payable under the benefit plan.


SIGN HERE (for ALL claims):____________________________________________DATE________________

Sign here to pay provider _________________________________________________DATE________________

Sign here to pay insured __________________________________________________DATE________________



WTF ONLY: DED PHCS MULTIPLAN NYCOV NYHOSP EFFDT ___________ EXPDT___________ INIT


WTF COMMENTS: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ANY PERSON WHO KNOWINGLY (AND WITH INTENT TO INJURE) DEFRAUDS OR DECEIVES ANY INSURANCE COMPANY, FILES A STATEMENT OF
CLAIM CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY, BE GUILTY OF A CRIMINAL ACT PUNISHABLE UNDER LAW.
*please note that the doctor’s medical credentials must be indicated on his/her submitted bill (ie.: MD, DC)

~ONLY ONE FORM NECESSARY PER MAILING OF MULTIPLE BILLS~