Claim Form - Burba Insurance Services Page 2
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Transamerica Worksite Marketing
Transamerica Occidental Life Insurance Company
P. O. Box 8063
Transamerica Assurance Company
Little Rock, AR 72203-8063
Transamerica Life Insurance Company
Monumental Life Insurance Company
1-800-251-7254
Life Investors Insurance Company of America
7 a.m. – 5 p.m. CST
Bankers United Life Assurance Company
Members of the AEGON Insurance Group
By furnishing this form, the Company does not admit that there is any insurance in force and does not waive any of its rights or defenses.
CLAIMANT’S STATEMENT
ADDRESS CHANGE __ Yes __ No
Insured’s Name: ____________________________________ Date of Birth: ________________ Policy Number(s): _____________
Employer: _____________________________________Occupation: _____________________Work Phone #: ________________
Patient’s Full Name: _________________________________Date of Birth: ______________ Relationship to Insured: ___________
Employer: _____________________________________Occupation: _____________________Work Phone #: ________________
IF ADDITIONAL SPACE IS NEEDED FOR ANY QUESTION, PLEASE USE AN ADDITIONAL SHEET OF PAPER AND ATTACH TO THIS FORM.
1. Nature of injury or illness: __________________________________When have you had this same or similar condition?________________________
2. When did symptoms first appear or accident occur: _______________________________________If an injury, explain fully how and where accident
occurred: __________________________________________________________________________________________________________
3. Date first treated/diagnosed: __________________________Name and address of physician (list all physicians consulted): _____________________
_____________________________________________________________________________________________________________________
4. What other health insurance do you have? (List all
companies)_______________________________________________________________________
5. Have you been confined to a hospital for this condition? ____________Admission date: _________________Discharge Date: ___________________
Please give name and address of hospital: __________________________________________________________________________________
__________________________________________________________________________________
6. Were you confined in an Intensive Care Unit during this hospital stay? _______________If so, for how many days?____________________________
7. If you had surgery, please give the name and address of the surgeon:_______________________________________________________________
____________________________________________________________________________________________________________________
8.
If you were unable to work due to this condition, please give dates. From ________________To ______________________If you were restricted to
to light duty due to this condition, please give dates. From ____________________To ____________________ When do you expect to resume your
usual duties? __________________________________________Are you filing a worker’s compensation claim? _________________________
9.
Have you ever been treated for or diagnosed as having had a heart attack, heart trouble or any abnormal condition of the heart; cancer; or diabetes prior to
the effective date of this policy?_______________ If so, when ______________________________ Please give the name and address of the
physician and/or hospital who treated you for this previous condition:_______________________________________________________________
_____________________________________________________________________________________________________________________
AUTHORIZATION
BANKERS UNITED LIFE
LIFE INVESTORS
MONUMENTAL LIFE
TRANSAMERICA LIFE
TRANSAMERICA
TRANSAMERICA
ASSURANCE COMPANY
INSURANCE COMPANY
INSURANCE COMPANY
INSURANCE COMPANY
OCCIDENTAL LIFE
ASSURANCE COMPANY
OF AMERICA
INSURANCE COMPANY
I certify that the above statements are true and correct to the best of my knowledge. I authorize any physician, practitioner or any hospital (including Veteran’s Administration or
governmental medical facility), clinic or other medical or medically related facility, any medical service organization, any insurance company, worker’s compensation carrier, Social
Security Office or any other institution or organization to provide the Company or an agent, attorney, consumer reporting agency or independent administrator, acting on its
behalf, any medical or other information, requested by it, including information relating to mental illness, use of drugs or use of alcohol concerning this or other illness or injury,
so that the same may be included as part of the proof submitted to the Company. I understand that in executing this authorization I waive the right for such information to be
privileged. A photocopy of this authorization shall be as valid as the original. This authorization is valid from the date signed for the duration of the claim. I understand that I, or
any authorized representative, will receive a copy of this authorization upon request.
DATE___________________SIGNED________________________________________________SIGNED___________________________________________________
(POLICYHOLDER’S SIGNATURE)
(SIGNATURE OF PATIENT IF SPOUSE OR DEPENDENT OVER AGE 18)
o
o
ADDRESS__________________________________________________________________________________________IS ADDRESS PERMANENT?
YES
NO
o
o
(STREET ADDRESS)
(CITY)
(STATE)
(ZIP)
TEMPORARY?
YES
NO
FRAUD STATEMENT
Any person who knowingly and with intent to defraud any insurance company or other persons, 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, subject to criminal prosecution and civil penalties.
By furnishing this form, the Company does not admit that there is any insurance in force and does not waive any of its rights or defenses.
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