I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO AMJO CORP OR
 

Name of Insured

_____________________________________
Insured's ID or Social Security No. _____________________________________
Insurance Co. Name _____________________________________
Insurance Co. Address _____________________________________
 

Signed by Insured

_____________________________________

Please print and mail or fax this document to Amjo for inclusion with your claim:

Amjo Corp
P.O. Box 8304 - West Chester, OH 45069
1-877-289-2656 (USA Only)
Tel: 513-942-2770 - Fax: 513-942-2771

Click Here to return to our Insurance Help Page.

 

If you are doing your own claim...  
then you do not need to complete this form. It is only needed if we are doing the claim for you. This permits your insurance company to pay us. When we receive payment from the insurance company, we'll contact you so that you can pay us the balance. We will not ship any product until payment in full is received.

 
Amjo Corp - 513-942-2770
USA Toll Free 1-877-BUY-AMJO
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