Content

<Manual Header>

<Opening - Unresolved>

<Transaction Grid>

<Pending Transactions>

<What Happens Next>

<Print Footer>

Sample

• This claim was not submitted for review, and as a result is not currently active.
• If you wish to continue with this claim, please contact <client contact info/customer service> to ensure the necessary information is gathered for claim review and action.
• If you do not wish to continue with this claim, no additional action is required.