Combined Insurance Company Of America Instructions For Filing Accident And Claim Forms (Page 2 of 3) in pdf

ClaIm #

comBINeD INsUraNce compaNY of amerIca

Canadian Head Office: Claims Department • P.O. Box 3720 MIP • Markham, ON L3R 0X5 • Fax: 905-754-4362

CLAIMANT’S STATEMENT — PLEASE PRINT

telephoNe

POLICY NUMBER(S)

FORM NUMBER(S)

Full Name oF INsured

mr.

mrs.

ms.

mIss

(FIrst, mIddle, last)

maIlINg address

spouse’s Name

(Number, street, apt. #)

CIty

provINCe

postal Code

heIght

bIrthdate

age

seX

WeIght

(moNth, day, year)

male

Female

oCCupatIoN

type oF WorK

Is thIs a WorKers’ CompeNsatIoN ClaIm?

yes

date oF aCCIdeNt

tIme oF aCCIdeNt

loCatIoN

INJurIes sustaINed

please desCrIbe IN detaIl hoW aCCIdeNt oCCurred

(attaCh dIagram or eXtra sheet IF NeCessary)

please

complete

for

accIDeNt

date oF FIrst symptoms

have you ever had same or sImIlar CoNdItIoN?

as oF thIs date

(moNth, day, year)

are you stIll

please

yes

IF yes, gIve date

totally dIsabled?

complete

Nature oF sICKNess

for

yes

sIcKNess

CONFIRMATION FROM HOSPITAL IS A MUST FOR A HOSPITAL CLAIM

hospItal Name aNd address

your doCtor’s Name aNd address

IN all cases,

please

complete

dates oF treatmeNts

for

(mm/dd/yyyy)

accIDeNt

aND

FIrst day oF total

last day oF total

sIcKNess

dIsabIlIty

(mm/dd/yyyy)

dates durINg WhICh I Was uNable to do all the dutIes

pertaININg to my usual oCCupatIoN

FIrst day oF partIal

last day oF partIal

dIsabIlIty

(mm/dd/yyyy)

dates durINg WhICh I Was uNable to do part oF the dutIes

pertaININg to my usual oCCupatIoN

EMPLOYER’S STATEMENT — PLEASE PRINT

Name aNd address oF employer

telephoNe

FIrst day oF abseNCe From WorK

returNed to WorK

partIally dIsabled

(mm/dd/yyyy)

From ____________________

to_____________________

sIgNature

tItle

date

(mm/dd/yyyy)

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize any health care professional, as well as any public or private health or social service establishment, any insurer, my employer or former employer,

Consumer reporting agency, any other organization or persons having records or information concerning me to furnish such records or information to the insurer

and its reinsurer, particularly medical information, to determine eligibility for benefits. In case of death, the beneficiary, the heir or the liquidator of my estate is

expressly authorized to supply the insurer, when required by the latter, with all the information and authorizations necessary to study the death benefit claim and

obtain the required justifications. A photocopy of this authorization has the same value 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.

This form to be fully completed and returned within 60 days.

294436 (01/2013)