Canadian Head Office: Claims Department
P.O. Box 3720 MIP • Markham, ON L3R 0X5 • Fax: 905-754-4362
PLEASE COMPLETE AND RETURN ON _______________________________
Claim #
CLAIMANT’S SUPPLEMENTARY STATEMENT —
PLEASE PRINT
Name
Telephone Number
Address
Please describe any complications of injury or illness since last report
List medical treatments received since last report
Doctor’s name and address
Treatment dates (MM/DD/YYYY)
Hospital where confined since last report
Date of hospitalization
From
To
Yes
No
Have you been totally disabled to this date?
MM/DD/YYYY
When did you resume part of your duties?
When did you resume all of your duties?
When do you expect to resume part of your duties?
When do you expect to resume all of your duties?
MY CLAIM IS ON THE FOLLOWING BASIS
MM/DD/YYYY
First day of total disability
Dates during which I was unable to perform all the duties
pertaining to my usual occupation
Last day of total disability
First day of partial disability
Dates during which I was able to perform part of the duties
pertaining to my usual occupation
Last day of partial disability
EMPLOYER’S STATEMENT
MM/DD/YYYY
First day of absence from work
Return to work
Partially disabled
From:
To:
Name of Employer
Signed on
Signature
Title
MM/DD/YYYY
AUTHORIZATION TO RELEASE INFORMATION
I HEREBY AUTHORIZE any hospital or physician who has attended me to disclose, when requested to do so by the Combined Insurance Company
of America, any and all information with respect to any illness or injury, medical history or treatment and to furnish copies of all hospital or medical
records. A photostatic copy of this authorization shall be considered as effective and valid as the original.
__________________________________________________________
_________________________________________________________
SIGNATURE OF CLAIMANT
DATE
(MM/DD/YYYY)
IMPORTANT: Please review your claim form. Is it complete? A form not fully completed may delay settlement of your claim.
Please also retain a copy of both sides of your completed claim form.
294441 (01/2013)