USAble Mutual Insurance Company

How To File a Claim

You may download a USAble Mutual Insurance Company claim form in PDF (portable document format). This file will allow you to print a copy for completing off-line.

Claim Form (19 KB PDF)

Once the form is completed, please sign and date it. Mail it to the following address:

USAble Mutual
P.O. Box 1151
Little Rock, AR 72203

A separate claim form must be submitted for each patient when sending bills to USAble Mutual.

If you have a problem downloading the form, please contact us.

The following is a breakdown of the claim form:

1. Group Number and Name
2. Employee's Social Security Number

Sections 3-11 request information about the patient:

3. Patient's Last Name, Complete First Name, Middle Initial
4. Date of Birth (Month, Day, Year)
5. Sex
6. Patient's Relationship to Employee (Self, Spouse, Child, Other--specify)
7. Diagnosis or Nature of Illness or Injury
8. Was this an accident?
9. If yes, date of accident
10. Was this an automobile accident?
11. Was the illness/accident related to employment?

Sections 12 -14 request information about the employee (contract holder):

12. Employee's Last Name, First Name, Middle Initial
13. Assignment: Payment for this claim should be made to (Hospital, Doctor, Employee)
14. Employee Address

Sections 15-20 request other insurance information:

15. Do you have other health insurance with a group or government program?
16. Name of Insured
17. Name and Address of Insured's Employer
18. Name and Address of Other Insurance Company
19. Policy Number (other company)
20. Type of coverage (Single or Family); Has the other insurance company paid on this claim? If yes, please submit a copy of their payment with these bills.