Field 11 b - Other Claim ID
The “Other Claim ID” is another identifier applicable to the claim.
NUCC INSTRUCTIONS: Enter the “Other Claim ID.” Applicable
claim identifiers are designated by the NUCC.
When submitting to Property and Casualty payers, e.g. Automobile, Homeowner’s,
or Workers’ Compensation insurers and related entities, the following qualifier
and accompanying identifier has been designated for use:
Y4 Agency Claim Number (Property Casualty Claim Number)
Enter the qualifier to the left of the vertical, dotted line. Enter the
identifier number to the right of the vertical, dotted line.
FOR WORKERS’ COMPENSATION OR PROPERTY & CASUALTY: Required if known. Enter
the claim number assigned by the payer.
MEDICARE INSTRUCTIONS - Form version 08/05: Enter employer's name, if applicable. If there is a change in the insured's insurance status, e.g., retired, enter either a 6-digit (MM | DD | YY) or 8-digit (MM | DD | CCYY) retirement date preceded by the word, "RETIRED."
Form version 02/12: provide this information to the right of the vertical dotted line.
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