Express Wellness Benefit Claim Form
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4EXPRESS WELLNESS BENEFIT CLAIM FORM
The Benefits Center
P.O. Box 100158, Columbia, SC 29202-3158
Toll-free: 1-800-635-5597 Fax: 1-800-447-2498
Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.
For use with policies issued by the following Unum Group [“Unum”] subsidiaries:
Unum Life Insurance Company of America Provident Life and Accident Insurance Company
OUR COMMITMENT TO YOU
We understand an illness or injury creates emotional, physical and financial challenges and we want to do whatever we can
to help you. You have our commitment to provide you with responsive service and to be understanding and sensitive to your
circumstances during the claim process.
When should you use this claim form?
Use this claim form to submit a claim for the Express Wellness Benefit:
Who is responsible for completing this claim form?
The information provided on this claim form will be used to evaluate your eligibility for wellness benefits. Incomplete or illegible
answers may result in a delay of benefit consideration.
• Insured/Patient Statement (page 2): Please complete this section of the claim form and mail or fax the completed form to the
address or fax number indicated above.
• Claim Fraud Statements (pages 3 and 4): A total of 30 states currently require some type of insurance fraud warnings on
claims and/or application forms stating that it is a crime to provide information to an insurer with an intent to defraud.
Questions?
If, at any time, you have questions about the claim process or need help to complete this form, please call the above toll-free
number. Our Contact Center is staffed with experienced professionals who can be contacted from 8 a.m. to 8 p.m. Eastern Time,
Monday through Friday.
CL-1144 (08/14)
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