Colonial Life Universal Claim Form PDF Details

In the intricate landscape of insurance claims, the Colonial Life Universal Claim Form stands as a pivotal document designed to streamline the process of filing claims for individuals covered under Colonial Life insurance policies. With directives for submission via fax or mail, it guides claimants through the necessary steps to ensure all pertinent information and documentation, such as medical records, diagnosis codes, and authorizations, are accurately provided to facilitate a smooth claim processing experience. The form intricately details the submission requirements, from medical documentation for the diagnosed condition to the inclusion of signed and dated authorizations, thereby illustrating a commitment to efficiency and claimant support. It also offers an Optional Service Release Agreement for claimants who wish to grant permission for their details to be shared with designated individuals, enhancing service flexibility and personalized care. Moreover, the form includes cautionary language regarding insurance fraud, underpinning the legal obligations and ethical standards expected in the claims process. This comprehensive approach embodied within the Colonial Life Universal Claim Form not only aids individuals in navigating the complexities of claim submission but also underscores the importance of transparency, accuracy, and legal adherence in the pursuit of claim settlements.

QuestionAnswer
Form NameColonial Life Universal Claim Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other nameslife universal claim form pdf, colonial life universal claim, colonial life universal claim forms, colonial life accident insurance company claim form

Form Preview Example

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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Fax this direction

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

Fax to: Claims 1.800.880.9325

Phone Number: 1.800.325.4368

SECTION 1

TO BE COMPLETED BY POLICY OWNER

 

Claimant name

__Male __Female

Birth Date

Claimant Social Security Number

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

 

 

 

 

(

)

Treating Doctor’s Name

Phone Number

Fax Number

Address (Street)

(City)

(State)

(Zip Code)

Primary Doctor’s Name

Phone Number

Fax Number

Address (Street)

(City)

(State)

(Zip Code)

Referring Doctor or Hospital Name

Phone Number

Fax Number

Address (Street)

(City)

(State)

(Zip Code)

Referring Doctor or Hospital Name

Phone Number

Fax Number

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.

Date the accident occurred (not when it was treated)

_______________

(MM/DD/YYYY)

Have you been treated for the same or similar condition prior to this occurrence?

___Yes ___No If yes, when? _______________

(MM/DD/YYYY)

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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Fax this direction

CERTIFICATION

Fax to: Claims 1.800.880.9325

Phone Number: 1.800.325.4368

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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Fax this direction

Fax to: Claims 1.800.880.9325

Phone Number: 1.800.325.4368

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 :

Admitting Diagnosis/ICD-9 Code :

Secondary Diagnosis/ICD-9 Codes :

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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Fax this direction

Fax to: Claims 1.800.880.9325

Phone Number: 1.800.325.4368

SECTION 5

TO BE COMPLETED BY PHYSICIAN

Patient's Name

 

Patient's DOB

 

 

What primary condition prevents the patient from working?

 

 

 

Symptoms:

 

Objective Findings:

Date first treated for this condition ____/____/_____ (MM/DD/YYYY) If pregnancy, what is EDC? ____/____/____ (MM/DD/YYYY)

Is condition due to accident? c Yes c No If yes, date and description of accident ___/___/___ (MM/DD/YYYY)

Are any secondary conditions preventing the patient from working?

If yes, what are these secondary conditions?

c Yes

c No

 

 

 

 

 

 

 

When did symptoms first appear?

Date of new patient consultation

Date of patient's last visit

____/____/_____ (MM/DD/YYYY)

____/____/_____ (MM/DD/YYYY)

____/____/_____ (MM/DD/YYYY)

 

 

 

 

List any test(s) performed and submit a copy of the results.

 

List any surgeries performed with the date and procedure code (CPT). (Attach a copy of the operative report)

Restrictions (What the patient SHOULD NOT do)

Limitations (What the patient CANNOT do)

How soon do you expect significant improvement in the patient’s medical condition?

c 1-2 months

c 3-4 months

c 5-6 months

c more than 6 months

Expected return to work

(MM/DD/YYYY)

Dates (MM/DD/YYYY) unable to work full-time

Dates (MM/DD/YYYY) unable to work part-time

Actual date released to return to work.

From:

To:

 

From:

To:

____/____/_____ (MM/DD/YYYY)

 

 

 

 

 

Does this patient have permanent

If not employed, list dates of house confinement:

House Confinement means you are kept

restrictions/limitations?

From_______________

To________________

at home by your condition. “At Home” means

c Yes

c No

 

(MM/DD/YYYY)

(MM/DD/YYYY)

in your house or yard. However you may

 

 

 

 

 

 

follow your doctor’s orders, even if it means

 

 

 

 

 

 

leaving home.

 

 

 

 

 

 

 

Please check the activities of daily living that the patient is unable to perform:

 

 

c dressing

c eating

c meal preparation

c toileting

c continence

c bathing

c transferring

 

 

 

Dates of Office visit (Last 3 months)

 

How often do you see the patient?

 

 

Have you referred patient for other types of consultation

Name and address of Specialist

cYes c No

Dates of Hospitalization (Last 3 months)

Name and Address of Hospital

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.

Signature of Physician

 

 

Date (MM/DD/YYYY)

Physician’s Specialty

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

Fax Number

Tax ID or SSN

(

)

(

)

 

 

 

 

 

 

 

 

 

 

Physician/Group Name

 

 

 

Patient Account Number

 

 

 

 

 

Mailing Address

 

 

 

Do you accept Medical Records request by Fax? c Yes c No

 

 

 

 

Was patient referred to you by another physician? c Yes c No

Do you have authorization on file to release information to

 

 

 

 

 

Colonial Life? c Yes c No

 

 

 

 

Provide the following information for referring doctor:

Phone number

Name:

 

 

 

(

)

 

 

 

 

 

Mailing Address

 

 

 

Fax number

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

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

12/09

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(MM/DD/YYYY)
For hourly employees:For salaried employees: Hourly rate of pay ___________ Hours worked per week ___________ Annual salary ___________
If salary includes commissions, attach a breakdown of commissions for the twelve months prior to date last worked.
Date returned to work: Full-time___________ Part-time___________/Hours per week_____ Expected return to work ___________
Date employment terminated_________________
Name and phone number of Workers’ Compensation carrier:
(MM/DD/YYYY) (MM/DD/YYYY)
(MM/DD/YYYY)
Dates approved for FMLA (if eligible)
From_______________ To_______________
Dates employee unable to work (Full-time)
From____________AM/PM To____________AM/PM
(MM/DD/YYYY)(MM/DD/YYYY)
Hire date________________________
Average number of scheduled hours per week______________
Date sick leave was exhausted_______________ Was employee at work when the accident or sickness occurred?
c Yes c No
Is a Workers’ Compensation claim being filed? c Yes c No
Date last worked__________________
(MM/DD/YYYY)
Employee name________________________________________

Fax to: Claims 1.800.880.9325

 

 

 

Fax this direction

Phone Number: 1.800.325.4368

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 6

TO BE COMPLETED BY EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(MM/DD/YYYY)

(MM/DD/YYYY)

 

 

(MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

Employee’s job title:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employee’s duties include:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lifting

c

Less than 15 lbs.

c

15 to 44 lbs.

c

over 45lbs.

 

 

 

 

 

 

 

 

 

 

Stooping/bending

c

none

 

c

seldom

c

frequent

 

 

 

 

 

 

 

 

 

 

Crawling/kneeling

c

none

 

c

seldom

c

frequent

 

 

 

 

 

 

 

 

 

 

Reaching/pulling/pushing

c

none

 

c

seldom

c

frequent

 

 

 

 

 

 

 

 

 

 

Repetitive motion

c

none

 

c

seldom

c

frequent

 

 

 

 

 

 

 

 

 

 

Management Duties

c

none

 

c

seldom

c

frequent

 

 

 

 

 

Sitting (number of hours each day):________________

Standing (number of hours each day)_____________

 

Walking (number of hours each day):________________ Climbing Stairs/Ladders (number of hours each day)_____________

Who should we contact for updates on return to work status? Name/Phone/E-mail (*Please print)

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 Employer and Attending Physician portions of the claim form.

Signed by ____________________________________________

Title ___________________________________________

Print name ____________________________________________

Date ___________________________________________

 

 

 

(MM/DD/YYYY)

Telephone Number (

)_________________________________

Fax Number (

)________________________________

E-mail Address (*Please print) ______________________________________________________________________________

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

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PHONE 1.800.325.4368

FAX 1.800.880.9325

Authorization for Colonial Life & Accident Insurance Company

For the purpose of evaluating my eligibility for insurance and eligibility for benefits under an existing policy/certificate including checking for and resolving any issues that may arise regarding incomplete or incorrect information on my application or claim forms, I hereby authorize the disclosure of the following information about me and, if applicable, my dependents, from the sources listed below to Colonial Life & Accident Insurance Company (Colonial Life) and its duly authorized representatives.

Health information may be disclosed by any health care provider or institution, health plan or health care clearinghouse that has any records or knowledge about me including prescription drug database

or pharmacy benefit manager, or ambulance or other medical transport service. Health information may also be disclosed by any insurance company, Medicare or Medicaid agencies or the Medical Information Bureau (MIB). Health information includes my entire medical record and insurance claim history but does not include psychotherapy notes. Non health information including earnings or employment history or any other facts deemed appropriate by Colonial Life to evaluate my application or claim forms may be disclosed by any entity, person or organization that has these records about me, including but not limited to my employer, employer representative and compensation sources, insurance company, financial institution or governmental entities including departments of public safety and motor vehicle departments.

Any information Colonial Life obtains pursuant to this authorization will be used for the purpose of evaluating and administering my claim for benefits. Some information obtained may not be protected by certain federal regulations governing the privacy of health information, but the information is protected by state privacy laws and other applicable laws. Colonial Life will not disclose the information unless permitted or required by those laws.

This authorization is valid for two (2) years from its execution or the duration of my claim,

whichever is earlier and a copy is as valid as the original. I know that I or my authorized representative may request a copy of this authorization and access to this information. This authorization may be revoked by me or my authorized representative at any time except to the extent Colonial Life has relied on the authorization prior to notice of revocation or has a legal right to contest coverage under the contract or the contract itself. If revoked, Colonial Life may not be able to evaluate my claim or eligibility for benefits. I may revoke this authorization by sending written notice to: Colonial Life & Accident Insurance Company, Claims Department, P. O Box 100195, Columbia, SC 29202-3195.

You may refuse to sign this form; however, Colonial Life may not be able to evaluate and administer your claim. I am the individual to whom this authorization applies or that person’s legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or personal representative.

X

XXX-XX-______________________

_______________

(Signature)

(Social Security Number — last 4 digits)

(Date of Birth)

__________________________________________________

____________________________

(Printed name of individual subject to this disclosure)

(Date Signed)

 

If applicable, I signed on behalf of the insured as ___________________________(indicate relationship).

If legal Guardian, Power of Attorney Designee, Conservator, Beneficiary or personal representative.

______________________________

___________________________

_____________

(Printed name of legal representative)

(Signature of legal representative)

(Date Signed)

 

Authorization

 

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