Reimbursement Request
This form is used only for single, specific claims. Do not use for bulk/bordereau billing
	* Payee
Mail To
Genesis Claim#					*Accident State	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY
* Payment Through					Billing Date
Submitted By
Email					Phone
Client Claim#					* Date of Loss
* Claimant#1			Claimant#2			Claimant#3
Loss	Paid To Date	O/S Reserves	Loss	Paid To Date	O/S Reserves	Loss	Paid To Date	O/S Reserves
Indemnity ($)			Indemnity ($)			Indemnity ($)
Medical ($)			Medical ($)			Medical ($)
Expense ($)			Expense ($)			Expense ($)
Subrogation ($)
2nd Injury Fund ($)
Attachments
# 1
# 2
# 3
# 4
# 5

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