Form 74606-6 - Colonial Life & Accident - Group Supplemental Indemnity Claim Form Page 3

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Section 2

Doctor’s Office/Urgent Care/Emergency Room Visit Benefit/Diagnostic Test Benefit

(Part 1 and/or Part2)

Claim due to: ____Accident ____ Sickness

Condition being treated:____________________________

Date the accident occurred ________________ (not when it was treated) Time of accident_______ am/pm

(MM/DD/YYYY)

Description of Accident:

Section 3

Preventive Care Test Benefit

Include a billing statement from your physician, medical practitioner, hospital, clinic, or medical facility

Section 4

Prescription Benefit

Medication (1):

Condition being treated:

Medication (2):

Condition being treated:

Medication (3):

Condition being treated:

Medication (4):

Condition being treated:

Attach a copy of the pharmacy detailed receipt or mail order pharmaceutical statement

CERTIFICATION

Policy owner’s Name__________________________________ Social Security #____________________

I have checked the answers on this claim form and they are correct. I certify under penalty of perjury that my

correct social security number is shown on this form. I acknowledge that I received the Claim Fraud Statements

on page 2 of this form and that I read the statement required by the State Department of Insurance for my state,

if my state was listed on the form. Fraud Warning: Any person who knowingly and with intent to

defraud any insurance company or other person files a statement of claim containing any

materially false information or conceals, for the purpose of misleading, information

concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Please remember to also sign and date the attached authorization required to process your

claim.

X_________________________

X _________________________

X__________________

Claimant’s Signature

Policy owner’s Signature

Date (MM/DD/YYYY)

Fax this direction.

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 3