Form 687 - Report Of Disability - Central States Of Omaha (Cso)

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SIDE 1
P.O. Box 34350 • Omaha, NE 68134-0350
When faxing forms, please
1-800-826-6587 • Fax: 1-800-325-9116
follow-up with originals by mail.
Central States Health & Life Co. of Omaha
WARNING: Any person who knowingly fi les a statement of claim containing false, incomplete or misleading information may be
subject to criminal and civil penalties.
REPORT OF DISABILITY
The furnishing of this form is neither an admission of coverage or liability by the Company nor a waiver of any rights or defenses.
INSTRUCTIONS:
After you have been continuously disabled beyond your required waiting period, please complete the following steps:
 Step 1 - Provide your Loan Information in Part I of this report
This must include the mailing address for the Lending Institution where the payment is made, and the loan/account number.
 Step 2 - Attach a copy of your monthly loan statement or payment coupon.
 Step 3 - You complete Part II below.
 Step 4 - Have your Employer complete the Employer’s Statement or if you are self-employed, you complete the Self-Employed Statement. These statements are in Part
III on Side 2 of this Report.
 Step 5 - Have the Physician who fi rst treated you for this condition complete Part IV on Side 2 of this Report.
 Step 6 - Return the completed Report and a copy of your monthly loan statement or payment coupon in the enclosed envelope.
We suggest that you keep in touch with your Lending Institution and make sure you keep your account current.
PART I
LOAN INFORMATION
Lending Institution Name and Address:
Loan Number
Be sure to attach a copy of your monthly loan statement or payment coupon.
PART II
INSURED’S STATEMENT
Insured’s Full Name
M F
Date of Birth
Mo.
Day
Year
Certifi cate/Policy Number
Social Security Number
Have you had any previous loans covered by CSO insurance?
Yes
No
If yes, please provide Certifi cate/Policy Number(s): _______________________________________________
Occupation/Duties
Name and Address of Employer
On what date did the fi rst symptoms of this sickness appear/or date of accident?
What sickness or injury was suffered? If injury, describe accident.
Date:
________________________________________________ ,_________
Date fi rst unable to work entirely because of present disability.
Have you been able to return to work in any capacity?
Yes
No
If yes, list dates you were able to do some work __________________________
Date:
________________________________________________ ,_________
Please indicate your next scheduled appointment date along with the name and address of the Doctor you will be seeing:
Appointment Date: ____________________________
Doctor’s Name and Address: _____________________________________________________________
List names of primary physician and other physician(s) who have treated you within the last 3 years. Attach additional sheet if necessary.
ADDRESS(ES):
PHONE NO.
DATE(S) OF TREATMENT:
Primary Physician: ___________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Physician treating disability: ___________________________________________________________________________________________
AUTHORIZATION TO OBTAIN INFORMATION
UNLESS ALL STATEMENTS ARE COMPLETED FURTHER PAYMENT MAY BE DELAYED.
I hereby authorize any physician or practitioner of the healing arts who has examined or treated me, and all hospitals, clinics or medically related facilities, insurance
companies, health maintenance organizations, government entity (Federal, State or Local) or other organization, institution or person, that has any information, records or
knowledge of me or my health, past or present, to furnish to Central States Health & Life Co. of Omaha (or its representatives) and to permit them to examine and copy
any such information. I understand that Central States Health & Life Co. of Omaha may disclose the information to reinsurers, agents, employees and others who have a
legitimate business interest in obtaining the information in connection with underwriting or claims processing with the company.
Such release may include information which may be considered a communicable or venereal disease which may include, but are not limited to diseases such
as Hepatitis, Syphilis, Gonorrhea, Acquired Immune Defi ciency Syndrome (AIDS), AIDS Related Complex (ARC) and HIV Infection. The information authorized
for release may include records involving psychiatric, drug abuse, and/or alcoholism.
Unless revoked, a copy of this authorization, or the original, shall be valid for the duration of the claim or 24 months from the date signed. I acknowledge that I may
revoke this authorization at any time. I acknowledge that I have a right to a copy of this authorization upon request.
X
Date _______________________________ Insured’s Signature
_____________________________________________ Phone ____________________________
Street Address _____________________________________________ City and State_________________________________________ Zip Code _________________
Form 687 13th Rev.
8-10

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