Claim Form - The Ccpoa Benefit Trust Fund
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1
2
3Claim Submission Instructions
for CCPOA Members
1) Be sure to complete the appropriate sections of the claim form and provide
all requested information.
2) Have the physician treating you complete the Attending Physician’s
Statement on page 2 .
3) If loss of time is claimed, have your employer or school complete the
Employer Statement on page 1.
4) If medical or hospital benefits are claimed, itemized bills must be attached.
Make sure the claimant’s name is on each attachment.
5) Be sure to sign the claim form on the bottom of page 1.
6 ) Fax both pages of the claim form and any itemized bills to 312-351-6930.
Faxing will expedite the processing of your claim.
7) You should receive status of your claim within 7 to 10 business days of our
receipt of your claim form.
Questions about your claim? Call 1-866-445-8865
P.O. Box 6700, Scranton, PA 18505-0700 –
The ACE Group of Companies
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