Colonial Supplemental Insurance Disability Claim Form And Instructions printable pdf download

Fax to: Claims 1-800-880-9325

Disability Claim

From:____________________________

Form and

Fax Number: ____________________

COLONIAL

SUPPLEMENTAL

INSURANCE

Oate:_ _ _ _ _ _ _ _ _ _ _ _ __

Instructions

Number of pages: ______

=-_________

for what happens next®

Your disability must be flied within 12 months of your date of loss unless you are legally·unable to do so.

What can I do to avoid delays?

Missing information will delay the processing of your claim.

• Complete Section 1.

• Sign and return the Authorization. (Reverse side of page 3)

• Sign and return the Certification on page 3.

• Have your doctor and employer complete their sections.

• Enclose copies of all bills connected with your claim, if applicable.

When should I expect a reply?

• If you are filing a claim for a sickness or health condition occurring within the first 6 to 24 months of your policyl

certificate (based on policy requirements), we need to determine if the condition is pre-existing. We may have to write

for this information which may delay your claim. Please include the Signed authorization with your claim and ask

your doctor to promptly respond to our request for medical information.

We will call you to advise when your claim information is in processing. Mail time is a large contributor to the time it takes

for our response to reach you. Mail may take up to four or five days each way.

To avoid mail delays:

• Fax your claim to us at 1-800-880-9325. If you fax your claim, please do not mail the original document but keep

it for your records. Please allow at least 48 hours for our automated service center to be updated with information

confirming receipt of your fax.

• Have your payment returned by overnight delivery by initialing the Service Release below. An $18.00 charge for this

service will be deducted from your claim payment. This cost is subject to rate increases by overnight carriers. Your

check will be sent overnight the next business day to the address on this form. If it is returned due to an incorrect

address, we will re-send by regular mail. We will only overnight payments of $100.00 or more. Payments will not

be over nighted to P.O. Box addresses. Your check will be delivered Monday through F;riday; however, the time

is not guaranteed.

OPTIONAL SERVICE RELEASE AGREEMENT - Please initial below as indicated.

I authorize Colonial Ufe & Accident Insurance Company to facilitate processing this claim by releasing its

(Initial)

details with my spouse or family member if he/she is inquiring on my behalf.

I authorize Colonial Ufe & Accident Insurance Company to facilitate processing this claim by releasing its

(Initial)

details with a local sales representative if he/she is inquiring on my behalf.

I authorize Colonial Ufe & Accident Insurance Company to facilitate processing thjs claim by discussing its

(Initial)

details with my plan administrator if he/she is inquiring on my behalf.

I authorize Colonial Life & Accident Insurance Company to communicate information on the status of this

(Initial)

claim throL1gh electronic' messaging at my home phone number as indicated on this form.

I understand messages will be left with any person answering the phone or on my voicemaillanswering

machine.

Yes, please deduct the $18.00 fee (cost subject to rate increases) to overnight any applicable benefits

(Initial)

from my claim payment for this claim. I understand this fee will be deducted for future payments for this

loss and payments overnighted as well unless I notify the company in writing to use normal mail service.

I understand payments under $100.00 will be sent by regular mail.

Authorized service options are valid for two (2) years from the date executed or for the duration of my claim, whichever is

earlier. I may revoke these options at any time by notifying Colonial in writing, but the revocation will not have any affect

on any action taken before receipt of the revocation. I may request access to this information. I am not required to agree

to any of these options to obtain my benefits. The information disclosed may be shared by us.

CLAIMANT NAME: _ _ _ _ _ _ _ _ _ _ _ _ _ __

SOCIAL SECliRITY NUMBER: _ _ _ __

Colonial Supplemental Insurance is the marketing brand for Colonial Life & Accident Insurance Company.

12/06

64387-2

Colonial Supplemental Insurance Disability Claim Form And Instructions

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