Combined Insurance Company Of America Instructions For Filing Accident And Health Claims Page 2
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4Any person who knowingly presents a false or fraudulent claim
Combined Insurance Worksite Solutions
for payment of a loss or benefit or knowingly presents false
A unit of Combined Insurance Company of America
information in an application for insurance is guilty of a crime
CLAIM DEPARTMENT • PO BOX 6700
and may be subject to fines and confinement in prison.
SCRANTON, PA 18505-0700
IMPORTANT INSTRUCTIONS FOR FILING CLAIM
The form must be completed in detail including the
employer’s statement on reverse side when filing for
PLEASE PRINT - DO NOT WRITE
disability.
C laimant’s Full Name
Relationship to Policyholder
Fulltime Student
(Mr. / Mrs. / Miss)
self
spouse
child
Yes
No
Please list other names that you may use such as maiden name, nickname, etc.
Social Security #
Area Code
Home Phone
(Last 4 digits)
(
)
Address (Mailing Address and No.)
City
State
Zip
Policy Number
E-Mail Address
Mo.
Day
Year
Height
Weight
Occupation
Birth Date
Briefly describe your occupational duties:
Employer’s Name and Complete Address:
Are you filing claim under Workers’ Compensation Act or Social Security Act?
Is claimant eligible for Medicaid or a similar state program?
If yes, please submit a copy of the award or denial, when received.
Yes
No
Yes
No
If you have other accident-sickness disability insurance give company name, address and monthly benefit amount. (if none, so state)
If claim
Date of first symptoms
Have you ever had same or similar condition?
is for
Mo.
Day
Year
Yes
No
If yes, give date
Mo.
Day
Year
/
/
SICKNESS
/
/
Please complete
Nature of sickness
Date of accident
Time of accident
Nature of injuries
If claim
Mo.
Day
Year
/
/
AM
PM
is for
Please state exactly where you were when accident occurred including a detailed description of how accident occured
ACCIDENT
Please complete
Hospital’s name and address and telephone #
Please complete
Attending physicians’ names and addresses
Dates of treatment
for both
ACCIDENT
AND
Mo.
Day
Year
Mo.
Day
Year
A) TOTAL DISABILITY: Between what dates
were you unable to perform any duties?
A) From
/
/
through
/
/
SICKNESS
Mo.
Day
Year
B)
/
/
B) DATE RETURNED TO WORK:
Claims
C) PARTIAL DISABILITY: Between what dates were
Mo.
Day
Year
through
Mo.
Day
Year
you able to perform only partial duties?
C) From
/
/
/
/
WOULD IT BE ALL RIGHT IF, DURING THE NEXT YEAR, WE MENTION YOUR CLAIM BENEFITS WHEN TALKING TO PROSPECTIVE POLICYHOLDERS ABOUT OUR CLAIM
SERVICE?
Yes
No
IF YOU WISH TO DISCONTINUE THIS AUTHORIZATION AT ANY TIME, PLEASE CALL US AT 1-800-544-9382. THANK YOU.
Mo.
Day
Year
DATED:
/
/
SIGNED: X
CLAIMANT’S SIGNATURE
If your policy is paid with pre-tax dollars, benefits paid may need to be reported to the IRS. Contact your employer regarding reporting requirements.
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.
Mo.
Day
Year
DATED:
/
/
SIGNED: X
CLAIMANT’S SIGNATURE
Form No. 000640-LA
R. (8/10)
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