Form Cl07353-3 - Insured'S Statement Of Loss
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4Claims Department
PO Box 21008
Dept 0514
Greensboro, NC 27420-1008
Phone 800-487-1485
INSURED’S STATEMENT OF LOSS
•
Please answer all questions completely.
•
Please feel free to contact us at 800-487-1485 if you have any questions regarding this form or its completion.
INSURED INFORMATION
Insured’s Name: ___________________________________________________________________________________
Policy/Certificate No.
_______________________________
Issued by
_______________________
(s):
(the Company):
Please list any other policy, contract or account held by our Insured that was issued or administered by any Lincoln Financial
Group company. ___________________________________________________________________________________
Date of Birth: ______________________________________ Social Security Number: ____________________________
Address: _________________________________________________________________________________________
City: _____________________________________________ State: _______ ZIP: _______________________________
Home Phone: ______________________________________ Email: __________________________________________
Does our Insured currently have a legal representative?
h Yes
h No
If yes, please complete below:
Name: ___________________________________________________________________________________________
Home Phone: ______________________________________ Work Phone: _____________________________________
Address: _________________________________________________________________________________________
City: _____________________________________________ State: _______ ZIP: _______________________________
Indicate the type of legal representative:
h Power of Attorney h Legal Guardian
h Conservator
Please attach a copy of the legal document.
CLAIM INFORMATION
Why are you requesting benefits at this time?
_______________________________________________
(reason for claim):
Primary Diagnosis
_______________________________________________________________________
(for this claim):
Date you are claiming benefits as of
_________________________________________________________
(mm/dd/yyyy):
Date care services began
_________________________________________________________________
(mm/dd/yyyy):
What type
of services are you currently, or will be receiving?
(s)
h Home Health Care
h Adult Day Care
h Respite Care
h Assisted Living
h Residential Care Facility
h Nursing Home
h Other: ______________________________________________________________________
Medical Provider who recommended care services: ________________________________________________________
Doctor’s Name: _________________________________________________ Phone: ____________________________
Address: _________________________________________________________________________________________
City: _____________________________________________ State: _______ ZIP: _______________________________
Date First Seen: _________________________________________________ Most Recent Visit: ___________________
Lincoln Financial Group is the marketing name for Lincoln National Corporation and its affiliates.
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CL07353-3
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