Benificiary Assignment

Benificiary Assignment

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

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	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
The company with the sunny disposition

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Yes! We accept Credit Cards