Claimant'S Statement For Cancer Claim - Life Insurance Company Of Alabama
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1
2CLAIMANT’S STATEMENT FOR CANCER CLAIM
LIFE INSURANCE COMPANY OF ALABAMA
P.O. BOX 349
GADSDEN, AL 35902
Email:
Your claim is extremely important to us. This form is furnished to assist you in presenting a claim for benefits. Please
answer ALL questions on the form, sign and date it. Include a Pathologist’s Report for Cancer claims. Please remit
the completed form along with an itemized statement of hospital expenses, surgeons and anesthesia charges. You
should mail all claim information DIRECTLY to the above address.
Policyholder’s Name____________________________________Policy No(s).__________________________
Address
___________________________________________________________________________________
Street
City
State
Zip
Phone (______)_________________SS No._______________________Date of Birth____________________
K
Check Here if New Address
THIS CLAIM IS ON:
Insured,
Your Spouse,
Your Child
Male
Female
K
K
K
K
K
If claim is on spouse or child, please complete the following:
Patient’s Name:_____________________________________________Date of Birth_________________
Relationship to Policyholder:_____________________________Social Security #______________________
What condition are you claiming?__________________________________________________________
Date doctor was first consulted for this condition______________________________________________
1st Doctor’s Name______________________________________________________________________
Address__________________________________________Phone___________________________________
2nd Doctor’s Name______________________________________________________________________
Address____________________________________________________________Phone______________
If you were hospitalized: Date Admitted___________________Date Discharged_____________________
Name of Hospital______________________________________Phone____________________________
IMPORTANT NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files a statement
of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medically related facility, insurance company,
government organization, Social Security Administration, employer, other organization, institution or person that has any records or
knowledge of me, my health (including any information relating to the use of drugs or alcohol, AIDS, or mental and physical history,
condition, advice or treatment), earnings or other insurance benefits, including any accounting information to my patient’s account, to
release this information to the Life Insurance Company of Alabama or its duly authorized representatives. A photocopy of this authoriza-
tion shall be as valid as the original. I agree that this Authorization shall be valid for three years from the date shown below.
Date_____________ Policyholder’s Signature__________________________________________
Date_____________ Adult Patient’s Signature__________________________________________
(If other than policyholder)
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