Claim Form - The Ccpoa Benefit Trust Fund Page 2
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1
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3COMBINED INSURANCE COMPANY OF AMERICA
Page 1 of 2
P.O. Box 6700 • Scranton, PA 18505-0700
Fax both pages of this form to: 312-351-6930.
For your protection alifornia law requires the following to appear on this form:
Any person who knowingly presents a false or fraudulent claim
for the payment of a loss is guilty of a crime and may be subject to fines and confinement to state prison.
PLEASE PRINT—DO NOT WRITE
CLAIMANT’S FULL NAME
E-MAIL ADDRESS
MR.
MRS.
MISS
PLEASE LIST OTHER NAMES THAT YOU MAY USE SUCH AS MAIDEN NAME, NICKNAME, ETC.
HOME PHONE
BUSINESS PHONE
MAILING ADDRESS (Street, City, State, Zip)
POLICY NUMBER(S)
PLAN NUMBER(S)
LAST PAYMENT DATE
a) . . . . . . . . /. . . . . . . . . . . /. . . . . . . .
a)
a)
MO.
DAY
YR.
HEIGHT
WEIGHT
BIRTH
DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
b) . . . . . . . . /. . . . . . . . . . . /. . . . . . . .
b)
b)
MO.
DAY
YR.
MO.
DAY
YR.
Is claimant eligible for Medicaid or a similar state program?
YES
NO
c) . . . . . . . . /. . . . . . . . . . . /. . . . . . . .
c)
c)
MO.
DAY
YR.
OCCUPATION
CCPOA Benefit Trust Fund
ARE YOU ALSO FILING CLAIM UNDER WORKERS’ COMP. ACT?
YES
NO
IF YOU HAVE OTHER ACCIDENT, SICKNESS OR HOSPITAL INSURANCE, GIVE COMPANY NAME
DATE OF FIRST SYMPTOMS
HAVE YOU EVER HAD SAME OR SIMILAR CONDITION?
IF CLAIM IS FOR
IF YES, GIVE DATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
. . . . . . . . . . . . /. . . . . . . . . . . . /. . . . . . . . . . . .
YES
NO
SICKNESS
MO.
DAY
YR.
MO.
DAY
YR.
NATURE OF SICKNESS
PLEASE
COMPLETE
DATE OF ACCIDENT
TIME OF ACCIDENT
NATURE OF INJURIES
. . . . . . . . . . . . /. . . . . . . . . . . . /. . . . . . . . . . . .
IF CLAIM IS FOR
. . . . . AM
. . . . . PM
MO.
DAY
YR.
ACCIDENTAL
PLEASE STATE EXACTLY WHERE YOU WERE WHEN ACCIDENT OCCURRED INCLUDING A DETAILED DESCRIPTION OF HOW ACCIDENT OCCURRED:
INJURY
(“ACCIDENT”)
PLEASE
COMPLETE
HOSPITAL’S NAME . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ADDRESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . STATE . . . . . . . . . . . . . . .
CONFINEMENT DATES: FROM . . . . . . . . . . /. . . . . . . . . . . . /. . . . . . . . . . . TO . . . . . . . . . . /. . . . . . . . . . . . /. . . . . . . . . . .
MO.
DAY
YR.
MO.
DAY
YR.
ATTENDING PHYSICIANS’ NAMES AND ADDRESSES
DATES OF TREATMENT
PLEASE COMPLETE
. . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
FOR BOTH
MO.
DAY
YR.
ACCIDENT
AND
. . . . . . . . . . . . /. . . . . . . . . . . . . /. . . . . . . . . . . . . . . . .
MO.
DAY
YR.
SICKNESS
A) TOTAL DISABILITY: BETWEEN WHAT DATES WERE
YOU UNABLE TO PERFORM ANY DUTIES?
THROUGH . . . . . . . . . . . . . . . . . . . . . . . . .
A) FROM . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
/
/
CLAIMS
MO.
DAY
YR.
MO.
DAY
YR.
B) DATE RETURNED TO WORK
B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
MO.
DAY
YR.
C) PARTIAL DISABILITY: BETWEEN WHAT DATES WERE
THROUGH . . . . . . . . . . . . . . . . . . . . . . . . .
YOU ABLE TO PERFORM ONLY PARTIAL DUTIES?
C) FROM . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
/
/
MO.
DAY
YR.
MO.
DAY
YR.
EMPLOYER’S STATEMENT (If student, please have school principal complete)
COMPLETE ONLY IF CLAIMING LOSS OF TIME
EMPLOYEE’S NAME
WORKERS’ COMPENSATION CLAIM
YES
NO
FILED FOR THIS DISABILITY?
NAME AND ADDRESS OF COMPENSATION CARRIER
DATE RETURNED TO WORK
(OR SCHOOL)
TOTAL DISABILITY: BETWEEN
PARTIAL DISABILITY: BETWEEN
. . . . . . . . . ./. . . . . . . . ./. . . . . . . . .
WHAT DATES DID EMPLOYEE
FROM . . . . . . ./. . . . . . ./. . . . . . .
TO . . . . . . . ./. . . . . . . ./. . . . . . . .
WHAT DATES DID EMPLOYEE
FROM . . . . . . ./. . . . . . ./. . . . . . .
TO . . . . . . . ./. . . . . . . ./. . . . . . . .
MO.
DAY
YR.
MO.
DAY
YR.
MO.
DAY
YR.
MO.
DAY
YR.
MO.
DAY
YR.
GIVE UP ALL DUTIES?
GIVE UP ONLY PART OF DUTIES?
DATE
TITLE
EMPLOYER’S SIGNATURE
TELEPHONE
AUTHORIZATION TO RELEASE INFORMATION
I authorize any hospital, medical practitioner, medically related facility, Prescription Drug Database, insurance company, state and federal government agency, the Internal Revenue Service,
employer, consumer reporting agency or the MIB (Medical Insurance Bureau) to release to Combined Insurance Company of America any information for the purpose of processing a claim.
Combined is also authorized to disclose such information to any doctor.This authorization or photocopy shall be valid for the duration of the claim. A copy is available upon request.
X
DATED: . . . . . . . . . . . . . . . . . . . . . . . . . . .
/
/
SIGNED:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MO.
DAY
YR.
CLAIMANT’S SIGNATURE (If Minor, Parent’s Signature)
Form No. 000640-CCPOA (3-11)
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