INSTRUCTIONS: ALABAMA ADA DENTAL CLAIM FORM

Alabama public employees receiving supplemental dental coverage administered by Southland Benefit Solutions can use the claim form discussed in this article. This document can be obtained from the website maintained by Southland Benefit Solutions.

Alabama ADA Dental Claim Form Step 1: In box 1, indicate the kind of transaction being documented with a check mark.

Alabama ADA Dental Claim Form Step 2: In box 2, enter the predetermination or preauthorization number.

Alabama ADA Dental Claim Form Step 3: In box 3, enter your dental benefit plan or insurance company name, address, city, state and zip code.

Alabama ADA Dental Claim Form Step 4: In box 4, indicate whether you have other dental or medical coverage with a check mark. If no, you can skip steps 5 through 11.

Alabama ADA Dental Claim Form Step 5: In box 5, enter the name of the policyholder or subscriber of the other dental or medical coverage.

Alabama ADA Dental Claim Form Step 6: In box 6, enter the date of birth of this policyholder or subscriber.

Alabama ADA Dental Claim Form Step 7: In box 7, indicate this policyholder or subscriber's gender with a check mark.

Alabama ADA Dental Claim Form Step 8: In box 8, enter their policyholder or subscriber ID. This can be either their Social Security number or ID number.

Alabama ADA Dental Claim Form Step 9: In box 9, enter the plan or group number.

Alabama ADA Dental Claim Form Step 10: In box 10, indicate the relationship of the patient to the person named in box 5 with a check mark.

Alabama ADA Dental Claim Form Step 11: In box 11, enter the name, address, city, state and zip code of the other insurance company or dental benefit plan.

Alabama ADA Dental Claim Form Step 12: In box 12, enter the name, address, city, state and zip code of the policyholder or subscriber of the insurance company named in box 3.

Alabama ADA Dental Claim Form Step 13: In box 13, enter this policyholder or subscriber's date of birth.

Alabama ADA Dental Claim Form Step 14: Indicate this policyholder or subscriber's gender with a check mark in box 14.

Alabama ADA Dental Claim Form Step 15: Complete the rest of the form as instructed.

INSTRUCTIONS: ALABAMA DEATH BENEFIT CLAIM FORM (Form B)

When an Alabama peace officer or fireman dies, their survivors may seek death benefits from the state by filing a form B death benefit claim form. This document can be obtained from the website of the Alabama Department of Finance. You must print or type all of your answers in ink.

Alabama Death Benefit Claim Form B Step 1: Enter your name on the line above the words "Name of Claimant."

Alabama Death Benefit Claim Form B Step 2: On line 1, enter your name and mailing address, as well as your home and business telephone numbers.

Alabama Death Benefit Claim Form B Step 3: On line 2, give the date of death of the fireman or police officer.

Alabama Death Benefit Claim Form B Step 4: On line 3, give the duration of the deceased's employment in that capacity.

Alabama Death Benefit Claim Form B Step 5: Line 4 states that you must attach a death certificate as documentation for your claim. You must also include an affidavit from the head of the agency which employed the deceased which states their employment status and provides a description of the circumstances leading to their death.

Alabama Death Benefit Claim Form B Step 6: Line 5 requires you to enter all surviving dependents, including spouses, children from a current or previous marriage and parents. Attach additional sheets as necessary. Give the full name and address of every dependent, as well as their relationship to the deceased and their age. Note whether they were receiving support from the deceased.

Alabama Death Benefit Claim Form B Step 7: On line 6, give the geographic location of the site of injury or death.

Alabama Death Benefit Claim Form B Step 8: On line 7, provide your explanation of the circumstances of death, including the name of the deceased. Attach additional sheets as necessary.

Alabama Death Benefit Claim Form B Step 9: If you are represented by an attorney, enter their name, address and telephone number.

Alabama Death Benefit Claim Form B Step 10: Sign the form in the presence of a notary public.

Alabama Death Benefit Claim Form B Step 11: File the form in duplicate along with all supporting documentary evidence. This must also be submitted in duplicate.