Transamerica Accident Claim Form

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Transamerica Life Insurance Company
Monumental Life Insurance Company
Administrative Office: P.O. Box 8043
Claim Package
Little Rock, AR 72203-8043
7 a.m. – 6 p.m. CST
Fax: 866-586-6528
By furnishing this form, the Company does not admit that there is any insurance in force and does not waive any of its rights or defenses.
1. Insured’s Full Name
2. Date of Birth
3. Policy or Certificate Number
4. Social Security Number
5. Address (include city, state and zip code)
6. Phone Number
7. Employer
8. Occupation
9. Work Phone Number
10. Patient’s Full Name
11. Date of Birth
12. Relationship to Insured
If additional space is needed for any question, please use an additional sheet of paper and attach to this form.
1. Nature of injury or illness
2. When have you had this same or similar condition?
3. When did symptoms first appear or accident occur? If an injury, explain fully how and where accident
4. Date first treated/diagnosed
5. Name and address of physician (list all physicians consulted)
6. What other health insurance do you have? (list all companies)
7. Have you been confined to a hospital for this condition?
8. Please give name and address of hospital.
Admission date:
Discharge Date:
9. Were you confined in an Intensive Care Unit during this hospital stay?
10. If you had surgery, please give the name and address of the surgeon
If yes, for how many days?
11. If you were unable to work due to this condition, please give dates.
12. If you were restricted to light duty due to this condition, please give dates.
13. When do you expect to resume your usual duties?
14. Are you filing a workers’ compensation claim?
15. If applying for waiver of premium, give dates of total disability.
16. Have you ever been treated for or diagnosed as having had a heart attack,
heart trouble or any abnormal condition of the heart; cancer; or diabetes prior
to the effective date of this policy?
If yes, when?
17. Please give the name and address of the physician and/or hospital who treated you for this previous condition.
I hereby certify that all information submitted in connection with this claim is true and correct to the best of my knowledge and belief, and I agree that all
information and materials subsequently submitted by me or on my behalf for this or any subsequent claim will be true and correct.
Claimant’s Signature: ________________________________________________
Date: ______________________
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