Critical Illness Benefit Claim Form (Page 3 of 3) in pdf

THE P TIENT IS RESPONSIBLE FOR COMPLETION OF THIS FORM WITHOUT EXPENSE TO THE COMP NY.

P RT B - ttending Physician's Statement

When did symptoms first appear or accident happen?

Date: ____________________________

Was condition due to:

_______disease

________injury

Diagnosis Code:

________________________________________________________________________

Diagnosis Detail:

________________________________________________________________________

(if loss of sight list the

________________________________________________________________________

central vision in each eye

________________________________________________________________________

Has patient ever had a same or similar condition?

_______Yes (explain)

_______No

________________________________________________________________________

Duration of Coma based on your knowledge of patient's background. (If claiming Coma Benefit)

______1-3 Months

_______3-6 Months

_______6-12 Months

______More than 12 months

Loss of Independent Living Benefit Claims-Select the activities of daily living that the insured is permanently unable to perform:

(See definition of each activity in the policy contract)

_____Bathing

______ Transferring

_____Dressing

______ Continence

_____Toileting

______ Eating

dditional Remarks: _________________________________________________________________________________________________

_________________________________________________________________________________________________________________

Doctor's Name __________________________________________________________________Date ______________________________

Street ____________________________________________________________________________________________________________

City _________________________________________ State ________ Zip Code ____________ Phone No.( ______ ) __________________

Doctor's License # _____________________ NPI # _____________________________

Doctor's Signature

If hospitalized as a result of this condition:

Hospital Name ___________________________________________________________________ NPI # _____________________________

Street ____________________________________________________________________________________________________________

City _________________________________________ State ________ Zip Code ____________ Phone No.( ______ ) __________________

dmission Date: ___________________________________________Discharge Date ____________________________________________

Page 3 of 3

GL 185 REV0915

Critical Illness Benefit Claim Form Page 3

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