Form 74606-6 - Colonial Life & Accident - Group Supplemental Indemnity Claim Form

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Group Supplemental

Fax to: Claims 1.800.248.9312

From:_____________________________

Indemnity Claim Form

No#of pages:_______________________

Or M ail t o: P .O. B ox 1 00195

Columbia, S C 2 9202-‐3266

Fax this direction.

Please b e s ure t o s end t he f ollowing I nformation:

 A b illing s tatement f rom y our p hysician, m edical p ractitioner, h ospital, c linic, o r m edical f acility

 Signed a nd d ated a uthorization

OPTIONAL S ERVICE R ELEASE A GREEMENT – P lease i nitial b elow f or o ptional s ervices. A ny o ther m arks

used ( check m ark, x , e tc.) w ill n ot b e c onsidered a s a uthorization a nd w ill b e p rocessed a s b lank.

I a uthorize C olonial L ife t o f acilitate p rocessing t his c laim b y r eleasing i ts d etails t o t he i ndividual

inquiring o n m y b ehalf. L eave b lank i f y ou d o n ot w ant a nyone a ccessing y our c laim i nformation.

_____sales r epresentative

_ ______ p lan a dministrator

_____spouse, f amily m ember o r s ignificant o ther: N ame___________________________________

_____I w ant C olonial L ife t o u pdate m e o n t he s tatus o f m y c laim t hrough e lectronic m essaging a t m y

home p hone n umber i ndicated o n t his f orm. M essages w ill b e l eft w ith a nyone t hat a nswers t he p hone

or o n m y a nswering m achine. T o a void b locked c alls, I s hould p rogram t he n umber 1 .800.325.4368 i nto

my p hone.

Y es, I w ant A LL p ayment(s) f or t his c laim s ent b y o vernight d elivery. I u nderstand p ayment(s) u nder

$100.00 c annot b e s ent o vernight a nd a $ 22.00 f ee, w hich i s s ubject t o r ate i ncreases b y c arrier a nd d oes

not i nclude w eekend d elivery, w ill b e d educted f rom m y c laim p ayment(s). W e a re u nable t o o vernight

mail t o a P .O. B ox a nd y ou m ust n otify u s i n w riting t o d iscontinue t his s ervice.

If your name has changed, please attach a copy of legal documentation (i.e. marriage certificate or driver’s license)

Section 1

To be completed by Policy owner

Claimant name

__Male __Female

Birth Date

Claimant Social Security Number

Policy owner (First, Last)

Birth Date

Social Security Number

Mailing Address (Street or PO Box)

Apartment number

(City)

(State)

(Zip)

Home telephone

Policy owner e-mail address

Work Telephone

7 4606-‐6

Colonial L ife p roduct a re u nderwritten b y C olonial L ife & A ccident i nsurance C ompany, f or w hich C olonial L ife i s t he m arketing b rand

08/13-‐Visit u s o nline a t C 1