Colonial Life Universal Claim Form – Fill Out and Use This PDF

	Fax to: Claims 1.800.880.9325	Fax this direction
	From: ___________________ Number of pages:______
	Or Mail to:
	P.O. Box 100266
	Columbia SC 29202-3266

Universal Claim Form

Please be sure to send the following Information:

Medical Documentation for your condition

Diagnosis (ICD9) codes,

Signed and dated authorization

OPTIONAL SERVICE RELEASE AGREEMENT – Please initial below for optional services. Any other marks used (check mark, x, etc.) will not be considered as authorization and will be processed as blank.

I authorize Colonial Life to facilitate processing this claim by releasing its details to the individual inquiring on my behalf. Leave blank if you do not want anyone accessing your claim information.

_____sales representative _____plan administrator

_____spouse, family member or signiicant other

_____I want Colonial Life to update me on the status of my claim through electronic messaging at my home phone number

indicated on this form. Messages will be left with anyone that answers the phone or on my answering machine. To avoid blocked calls, I should program the number 1.800.325.4368 into my phone.

_____Yes, I want ALL payment(s) for this claim sent by overnight delivery. I understand payment(s) under $100.00 cannot be

sent overnight and an $18.00 fee, which is subject to rate increases by carrier and does not include weekend delivery, will be deducted from my claim payment(s). We are unable to overnight mail to a P.O. Box and you must notify us in writing to discontinue this service.

*WELLNESS/HEALTH SCREENING

If you wish to ile a Wellness/Cancer Screening claim for a test performed within the past 12 months, we need to submit the type and date of the test performed as well as your doctor’s name and phone number. We also need to know if this is for you or another covered individual and their name and social security number. You may:

•FILE BY PHONE! Call 1.800.325.4368 and provide the information requested by our Automated Voice Response System, 24 hours per day, 7 days a week, or

•SUBMIT ON THE INTERNET using the Wellness Claim Form at coloniallife.com, or

•Write your name, address, social security number and/or policy/certiicate number on your bill and indicate “Wellness Test.” FAX this to us at 1.800.880.9325 or MAIL to P.O. Box 100195, Columbia SC 29202.

If you ile by telephone or internet please retain a copy of the medical information and/or your receipt if needed for further veriication.

If your Wellness/Cancer Screening test was more than one year ago, you must fax or mail us a copy of the bill or statement from your doctor indicating the type of procedure performed, the charge incurred and the date of service. Please write your full name, social security number, and current address on the bill.

Please note: If your cancer policy includes a second part to the screening beneit, bills for covered tests and a copy of the diagnostic report (relecting the abnormal reading of your irst test) must be mailed or faxed to us for beneits to be provided.

*CANCER

Please complete the sections that apply to your coverage.

•For Internal Cancer – Attach a copy of the pathology report from your initial diagnosis.

•Attach copies of itemized statements for all medical expenses incurred relating to the diagnosis and treatment of your malignancy. Please clearly write your name and social security number on each bill.

•For Skin Cancer – Attach a copy of your pathology report for each date of service a lesion was biopsied and/or removed. Also, please include a copy of your itemized bills that provide the surgical procedure code(s) and charges for each lesion removed. This information should provide all doctors complete names, mailing addresses and telephone numbers.

•Transportation and Lodging – Please review your policy to determine what expenses are covered. Send us a statement detailing your transportation and lodging expenses. This information should include mileage, where you traveled from and to, lodging receipts and medical veriication of treatment for this time.

•If you are claiming disability, please have your employer and doctor provide any applicable information under SECTIONS 5 & 6.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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Claim Fraud Statements

For your protection, the laws of several states, including Alaska, Arkansas, Delaware, Idaho, Indiana, Louisiana, Minnesota, New Hampshire, Ohio, Oklahoma, and others require the following statement to appear on this claim form.

Fraud Warning : Any person who knowingly, and with intent to injure, defraud, or deceive an insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of insurance fraud, which is a felony.

Arizona Residents : For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California, Texas and West Virginia Residents : For your protection, California, Texas and West Virginia law requires the following to appear on

this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado Residents : It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia and Maryland Residents : WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida Residents : Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky : For your protection, Kentucky law requires the following to appear on this form: 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.

Maine, Tennessee, Virginia and Washington Residents : It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.

New Jersey and New Mexico : Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Pennsylvania Residents : Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or 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 and subjects such person to criminal and civil penalties

Oregon Residents : Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.

Puerto Rico Residents : Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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SECTION 1

TO BE COMPLETED BY POLICY OWNER

Relationship to Policy Owner: ___ spouse ___ dependent ___self ____domestic partner

Policy owner (First, Last)		Birth Date		Social Security Number
Mailing Address (Street or PO Box)				(Apartment/Unit/Lot number)
(City)	(State)		(Zip)	Home telephone number
				(	)
Policy owner e-mail address (*Please print)				Work telephone number
				(	)

Address (Street)

(City)

(State)

(Zip Code)

Address (Street)

(City)

(State)

(Zip Code)

Address (Street)

(City)

(State)

(Zip Code)

SECTION 2

TO BE COMPLETED BY POLICY OWNER

ACCIDENTAL INJURY- please complete and attach itemized copies of any related bills including doctor, ambulance, emergency room, hospital, and/or rehabilitation unit. Bills should include diagnosis information from your medical provider.

Check One:_______________On-Job_______________Off-Job

Description of accident (if auto accident, attach a copy of the traffic report)

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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Policy owner 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 iles 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)
SECTION 3	TO BE COMPLETED BY PHYSICIAN

ROUTINE PREGNANCY (6 weeks for vaginal delivery or 8 weeks for c-section, less the elimination period)

Date of Delivery ______________	Hospital Admission Date:	Hospital Discharge Date :
(MM/DD/YYYY)	______________	______________
___ Vaginal ___C-section	(MM/DD/YYYY)	(MM/DD/YYYY)
First Date of Treatment, Advice, Medication : __________________
	(MM/DD/YYYY)

List other Date of Treatments, for this pregnancy : _____________				_____________ ______________
		(MM/DD/YYYY)		(MM/DD/YYYY)			(MM/DD/YYYY)
_____________	_____________	_____________	_____________			_____________
(MM/DD/YYYY)	(MM/DD/YYYY)	(MM/DD/YYYY)	(MM/DD/YYYY)				(MM/DD/YYYY)
Doctor’s Name					Doctor’s Phone : (			)
					Fax : (		)
					Tax ID or SSN:
Doctor’s Address (Street)		(City)			(State)			(Zip Code)

FRAUD NOTICE: Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. This includes Attending Physician portions of the claim form.

Doctor’s Signature		Date: __________________
				(MM/DD/YYYY)
Referring Physician’s name and address		Doctor’s Phone : (			)
		Fax : (		)
Hospital Name		Hospital Phone
		(	)
Hospital’s Address (Street)	(City)	(State)			(Zip Code)

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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SECTION 4

Hospital Confinement/Hospital Intensive Care Unit Confinement Benefits

Refer to your certificate for required proof of loss requirements. Ask your medical provider to complete the following section.

Include a copy of the hospital bill(s) showing the admission and discharge dates, the daily room charge(s) and the medical expenses incurred. Please send a copy of the anesthesiology bill if outpatient surgery was performed.

Hospital Name			Phone Number :
			(	)
Hospital Address: (Street)	(City)	(State)		(Zip Code)
Admitting Doctor’s Name :			Phone Number :
			(	)
Admitting Doctor’s Address: (Street)	(City)			(State)	(Zip Code)
Hospital Confinement Dates : From _________________ To ____________________
(MM/DD/YYYY)		(MM/DD/YYYY)
Intensive Care Unit Confinement Dates : From _________________		To __________________
	(MM/DD/YYYY)			(MM/DD/YYYY)
Rehabilitation Unit : From _________________ To __________________
(MM/DD/YYYY)	(MM/DD/YYYY)
Surgery/Inpatient : From ______________	To _______________
(MM/DD/YYYY)	(MM/DD/YYYY)
Procedure Description/Procedure Code :
Surgery/Outpatient : From ______________	To _______________
(MM/DD/YYYY)	(MM/DD/YYYY)

Procedure Description/Procedure Code :

Date(s) of Doctor Office Visit(s) following outpatient surgery :

_____________ _____________ ______________

(MM/DD/YYYY) (MM/DD/YYYY) (MM/DD/YYYY)

If hospital confinement is for pregnancy or pregnancy complications, please provide the date the pregnancy was diagnosed __________

(MM/DD/YYYY)

Date of delivery : _________________	Type of delivery : ____Vaginal ____ C-section		Procedure Code for delivery _____________
(MM/DD/YYYY)
Referring Doctor’s Name:		Phone Number :
		(	)
Referring Doctors Address: (Street)	(City)		(State)	(Zip Code)

FRAUD NOTICE: Any person who knowingly files a statement of claim containing false or misleading information is subject to criminal and civil penalties. This includes Attending Physician portions of the claim form.

Doctor’s Signature (completing this form):		Date :________________
		(MM/DD/YYYY)
Tax ID or SSN :	Phone Numbers: ( )	Fax Number: ( )

Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

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