Statement Of Claim - Cancer Insurance

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STATEMENT OF CLAIM – CANCER INSURANCE
1. This claimant’s statement must be completed in full by the insured and
INSTRUCTIONS
2. The reverse side must be completed and signed by the attending physician.
3. Attach the appropriate medical bills and if applicable Medicare Explanation of Benefits
HOW TO
4. Include a pathology report verifying malignancy with all initial claims
SUBMIT
5. Send the completed claim form to the address below
A CLAIM
ATTENTION CLAIMS
Mercer Consumer, a service of Mercer Health & Benefits Administration LLC
PO BOX 10418
DES MOINES IA 50306
CLAIMANT’S STATEMENT
Name of Insured
Social Security Number
Sex
Date of Birth
Single
Male
Married
Female
______
Address
City
State
Zip
Telephone No.
(
) ________________
Name of Patient
Social Security Number
Relationship to Insured
Date of Birth
Self
Son
Spouse
Daughter
Other ________________
Nature of Illness – Describe
Date of First Treatment
Give name and complete mailing address of family and attending physicians
Name
Address
Phone
(
)
(
)
I certify that the statements contained hereon are true and correct to the best of my knowledge and belief and I authorize the health care provider named below (if specified) or
any medical professional, hospital or other medical care institution, pharmacy, governmental agency, insurance company, employer to provide (Monumental Life Insurance
Company – Direct Response Division or any agent, attorney, consumer reporting agency or independent administrator, acting on its behalf, information concerning advice, care
or treatment provided the patient, employee or deceased named below, including information relating to mental illness, use of drugs or use of alcohol. I also authorize my
employer to provide (Monumental Life Insurance Company – Direct Response Division) with financial or employment-related information. A photostatic copy of this form will be
as valid as the original.
SPECIAL NOTICE – Any person who knowingly, and with intent to injure, defraud, or deceive any insurance company, files a statement of claim containing and false,
incomplete or misleading information may be guilty of a criminal act punishable under law.
FOR OHIO ONLY – Any person who, with intent to defraud or knowing that he is facilitating fraud against an insurer, submits an application or files a claim containing a false or
deceptive statement is guilty of insurance fraud.
Signature of Insured
Date
Patient’s Signature
Date
TO BE COMPLETED BY INSURANCE PLAN ADMINISTRATOR
Policy Number
Certificate Number
Date of Birth
Original Date of Coverage
___________________
Coverage Elected:
Insured Only
Insured & Spouse
Insured’s Effective Date of Insurance
___________________
Insured and All Dependents
Dependent’s Effective Date of Insurance
___________________
Increased Coverage:
Has Insurance Terminated?
Yes
No (If Yes – Date) ___________________
Date of Increase:
Premium Paid To: ___________________________________
Name of Administrator
Signature of Administrator’s Representative
Title
Date
ATTENDING PHYSICIAN’S STATEMENT

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