Form Cl07353-3 - Insured'S Statement Of Loss Page 2

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CARE SERVICES
Individual Caregiver
Please provide us with information regarding care services provided by an individual caregiver.
Name: ___________________________________________________________________________________________
Relationship: ______________________________________________________________________________________
Care Services Provided: _____________________________________________________________________________
______________________________________________________________ Hrs/Days: __________________________
Contact Phone: ____________________________________________________________________________________
Facility/Agency
Please provide us with information regarding care services received which have been provided by an agency or medical
professional such as Assisted Living, Nursing Home or other facilities.
Agency Name: _____________________________________________________________________________________
Care Services Provided: _____________________________________________________________________________
Date
of Service: __________________________________________________________________________________
(s)
Contact Name: __________________________________________________ Contact Phone: ______________________
Agency Name: _____________________________________________________________________________________
Care Services Provided: _____________________________________________________________________________
Date
of Service: __________________________________________________________________________________
(s)
Contact Name: __________________________________________________ Contact Phone: ______________________
ACTIVITIES OF DAILY LIVING
Please review each activity of daily living and provide an objective assessment of our Insured’s current functional ability by
checking the most appropriate response for each activity. Space is provided for comments/notes.
Rating Scale:
0 = Without assistance
1 = Supervised
2 = Hands-on assistance
3 = Completely dependent
Task Description:
1. Bathing
h 0
h 1
h 2
h 3
2. Dressing
h 0
h 1
h 2
h 3
3. Eating/Feeding h 0
h 1
h 2
h 3
4. Toileting
h 0
h 1
h 2
h 3
5. Transferring
h 0
h 1
h 2
h 3
6. Continence
h 0
h 1
h 2
h 3
Is there a cognitive deficit present? h
No
Yes
h
NOTES: __________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Page 2 of 4
CL07353-3
11/13

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