Form 6554 5/10 - Claim Form For Accident Policy
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1
2Claim Form for Accident Policy
Employee’s Statement of Claim (To Be Completed By Employee)
Your Name ________________________________________ Social Security No. _______________ Policy No. _________________
Street Address ___________________________________________________________________ Is this a new address? r Yes r No
City _____________________________________________ State __________________________ ZIP Code ________________
Telephone No. (Area Code First) _________________________ Sex r Female r Male Is Claimant
r Employee r Dependent
Claimant’s Name (If other than employee) ____________________________________________ Date of Birth __________________
Employer’s Name and Location __________________________________________________________________________________
Occupation (List duties of your occupation at the time of accident) _____________________________________________________
Date of Accident ____________________________________ Place Accident Occurred ____________________________________
Describe how the Accident occurred _____________________________________________________________________________
___________________________________________________________________________________________________________
Is this Accident or illness related to your occupation?
r Yes
r No
If yes, explain: ___________________________________
___________________________________________________________________________________________________________
Have you or do you intend to file a Workers’ Compensation or Occupational Disease Law Claim?
r Yes
r No
Date you were first treated for your injury _______________________
Name and address of the hospital where you were treated _____________________________________________________________
___________________________________________________________________________________________________________
Name and address of the doctor who treated you ____________________________________________________________________
___________________________________________________________________________________________________________
Any person who knowingly present a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
The above statements are true to the best of my knowledge and belief.
____________________________________________________
_________________________
Signature of Insured
Date
I authorize Kanawha to deduct any premiums due from my disability benefit check:
r To pay my policy current
r For my entire claim
r For this payment only
____________________________________________________
_________________________
Signature of Insured
Date
Please attach all bills for treatment of this accident along with any accident reports.
Please note that a police report is required for all automobile accidents.
All bills must contain diagnosis and procedure codes.
email:
210 South White Street • Lancaster, SC 29720
Mail: PO Box 2000 • Lancaster, SC 29721-2000
6554 5/10
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Parent category: Business