Form 10304 - Disability Insurance Claim Page 2
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2details of accident or maternity claim – to be comPleted by the Physician
18-B. MATErNITY:
18-A. ACCIDENT:
On what date was the patient injured?
Estimated Date of Delivery (EDC)
Where (place) was the patient injured?
Prenatal Complications
how was the patient injured?
Date of Delivery
Post-partum Complications
19. I have treated the insured for the condition listed and, for the period claimed. The insured has been under my continuous care.
has the above patient been released to return to
Physician’s Name and Address (Please type or print.)
work?
h Yes
Date to return (Mo./Day/Yr.)
h No
Approximate Date of return
(Mo/Day/Yr.)
Phone No. (Indicate area code.)
h No
Will not return to work. Disability is
Date
total and permanent.
Physician’s Signature
h Date of Next Office visit
Part iii – emPloyer information
20. Workers’ Compensation: Is there possible Workers’ Compensation liability?
h Yes (If yes, complete this section.)
h No
Date accident/sickness reported
Date Workers’ Compensation claim filed
Current status of Workers’ Compensation claim:
h Approved
h Denied
h Pending
h Not Filed
Name and Address of Workers’ Compensation Payment Office
21. A. Is employee eligible to receive salary continuation, PTO, sick leave, vacation, etc?
h Yes h No
If Yes, please provide dates from ________________ to _________________.
B. Is employee subject to child support withholdings?
h Yes h No
If Yes, provide appropriate documentation with claim.
22. Is employee enrolled in the Companion Long Term Disability plan?
h Yes
h No
If “Yes,” effective date:
23. Name and Address of group
Phone No. and Area Code
24. group No.
(
)
25. I certify that the above insured was a full-time active employee and that he or she did not perform any duties pertaining to his or her occupation during the
period claimed above in block 10.
Employer’s Signature
Date
26. First Day Not at Work
27. Date returned to Work
28. Amount of Weekly Earnings:
29. Amount of Weekly Benefit
Mo.
Day
Yr.
Mo.
Day
Yr.
$
$
instructions for filinG claim for Weekly disability benefits
The reverse of this form should be completed by the insured employee, the employer and the insured’s attending physician as soon as possible after
the onset of the accident or sickness for which claim is made. If accident or maternity, details must be stated above.
The date we need a doctor’s statement of continuing disability will be indicated on the check stub each week. To prevent delays in weekly disability
payments, submit the doctor’s statement to Companion Life 10 days before this date occurs.
Weekly disability checks are mailed to the employer’s address.
When your employee returns to work, please call our Claims department to notify us immediately and then follow up with the final claim. Notifications
can be faxed to:
(803) 735-1251 Ext. 45922
(803) 754-1153 FAx
Claims should be forwarded to:
Companion Life Insurance Company
Attention: Claims Department
P.O. Box 100102
Columbia, South Carolina 29202-3102
By furnishing this blank form and investigating the claim, Companion Life Insurance Company shall not be held to admit the validity of any claim,
or to waive or breach any terms or conditions of the policy.
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