If you are a policy holder with Colonial Life and have been in an accident, you will need to file a universal claim form. This form can be used for any type of accident, whether it was your fault or not. Filing a claim as soon as possible is important, so we've put together some instructions on how to do so. Keep reading for information on what to include in your Colonial Life universal claim form and where to send it. If you're a policy holder with Colonial Life, then you'll need to know how to file a universal claim form. A universal claim form can be used for any type of accident, whether it was your fault or not. So if you've been in an accident, it's important
| Question | Answer |
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| Form Name | Colonial Life Universal Claim Form |
| Form Length | 8 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min |
| Other names | life universal claim form pdf, colonial life universal claim, colonial life universal claim forms, colonial life accident insurance company claim form |
Fax to: Claims 1.800.880.9325 |
Fax this direction |
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From: ___________________ Number of pages:______ |
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Or Mail to: |
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P.O. Box 100266 |
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Columbia SC |
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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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73702 |
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 |
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Claimant name |
__Male __Female |
Birth Date
Claimant Social Security Number
Relationship to Policy Owner: ___ spouse ___ dependent ___self ____domestic partner
Policy owner (First, Last) |
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Birth Date |
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Social Security Number |
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Mailing Address (Street or PO Box) |
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(Apartment/Unit/Lot number) |
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(City) |
(State) |
(Zip) |
Home telephone number |
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Policy owner |
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Work telephone number |
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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
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.
12/09 |
3 |
73702 |
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.
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_____________________________________ _____________________________________ |
____/____/____ |
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Claimant’s Signature |
Policy owner’s Signature |
Date (MM/DD/YYYY) |
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SECTION 3 |
TO BE COMPLETED BY PHYSICIAN |
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ROUTINE PREGNANCY (6 weeks for vaginal delivery or 8 weeks for
Date of Delivery ______________ |
Hospital Admission Date: |
Hospital Discharge Date : |
(MM/DD/YYYY) |
______________ |
______________ |
___ Vaginal |
(MM/DD/YYYY) |
(MM/DD/YYYY) |
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First Date of Treatment, Advice, Medication : __________________ |
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(MM/DD/YYYY) |
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List other Date of Treatments, for this pregnancy : _____________ |
_____________ ______________ |
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Doctor’s Name |
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Doctor’s Phone : ( |
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Fax : ( |
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Tax ID or SSN: |
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Doctor’s Address (Street) |
(City) |
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(State) |
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(Zip Code) |
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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 |
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Date: __________________ |
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Referring Physician’s name and address |
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Doctor’s Phone : ( |
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Fax : ( |
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Hospital Name |
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Hospital Phone |
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Hospital’s Address (Street) |
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Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
12/09 |
4 |
73702 |
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 |
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Phone Number : |
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Hospital Address: (Street) |
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Admitting Doctor’s Name : |
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Phone Number : |
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Admitting Doctor’s Address: (Street) |
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(State) |
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Hospital Confinement Dates : From _________________ To ____________________ |
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(MM/DD/YYYY) |
(MM/DD/YYYY) |
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Intensive Care Unit Confinement Dates : From _________________ |
To __________________ |
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(MM/DD/YYYY) |
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(MM/DD/YYYY) |
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Rehabilitation Unit : From _________________ To __________________ |
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Surgery/Inpatient : From ______________ |
To _______________ |
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(MM/DD/YYYY) |
(MM/DD/YYYY) |
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Procedure Description/Procedure Code : |
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Surgery/Outpatient : From ______________ |
To _______________ |
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(MM/DD/YYYY) |
(MM/DD/YYYY) |
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Procedure Description/Procedure Code :
Admitting
Secondary
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 ____ |
Procedure Code for delivery _____________ |
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Referring Doctor’s Name: |
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Phone Number : |
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Referring Doctors Address: (Street) |
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(Zip Code) |
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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 :________________ |
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(MM/DD/YYYY) |
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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.
12/09 |
5 |
73702 |
Fax this direction
Fax to: Claims 1.800.880.9325
Phone Number: 1.800.325.4368
SECTION 5 |
TO BE COMPLETED BY PHYSICIAN |
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Patient's Name |
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Patient's DOB |
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What primary condition prevents the patient from working? |
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Symptoms: |
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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? |
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c Yes |
c No |
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When did symptoms first appear? |
Date of new patient consultation |
Date of patient's last visit |
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____/____/_____ (MM/DD/YYYY) |
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List any test(s) performed and submit a copy of the results. |
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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 |
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c more than 6 months |
Expected return to work
(MM/DD/YYYY)
Dates (MM/DD/YYYY) unable to work |
Dates (MM/DD/YYYY) unable to work |
Actual date released to return to work. |
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From: |
To: |
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From: |
To: |
____/____/_____ (MM/DD/YYYY) |
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Does this patient have permanent |
If not employed, list dates of house confinement: |
House Confinement means you are kept |
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restrictions/limitations? |
From_______________ |
To________________ |
at home by your condition. “At Home” means |
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c Yes |
c No |
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(MM/DD/YYYY) |
(MM/DD/YYYY) |
in your house or yard. However you may |
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follow your doctor’s orders, even if it means |
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leaving home. |
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Please check the activities of daily living that the patient is unable to perform: |
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c dressing |
c eating |
c meal preparation |
c toileting |
c continence |
c bathing |
c transferring |
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Dates of Office visit (Last 3 months) |
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How often do you see the patient? |
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Have you referred patient for other types of consultation |
Name and address of Specialist |
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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 |
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Date (MM/DD/YYYY) |
Physician’s Specialty |
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Telephone Number |
Fax Number |
Tax ID or SSN |
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Physician/Group Name |
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Patient Account Number |
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Mailing Address |
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Do you accept Medical Records request by Fax? c Yes c No |
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Was patient referred to you by another physician? c Yes c No |
Do you have authorization on file to release information to |
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Colonial Life? c Yes c No |
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Provide the following information for referring doctor: |
Phone number |
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Name: |
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Mailing Address |
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Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
12/09 |
6 |
73702 |
Fax to: Claims 1.800.880.9325
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Fax this direction |
Phone Number: 1.800.325.4368 |
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SECTION 6 |
TO BE COMPLETED BY EMPLOYER |
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(MM/DD/YYYY) |
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Employee’s job title: |
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Employee’s duties include: |
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Lifting |
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Less than 15 lbs. |
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15 to 44 lbs. |
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over 45lbs. |
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Stooping/bending |
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none |
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seldom |
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frequent |
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Crawling/kneeling |
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none |
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seldom |
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frequent |
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Reaching/pulling/pushing |
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none |
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seldom |
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frequent |
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Repetitive motion |
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none |
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seldom |
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frequent |
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Management Duties |
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none |
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seldom |
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frequent |
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Sitting (number of hours each day):________________ |
Standing (number of hours each day)_____________ |
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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?
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 ___________________________________________ |
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Print name ____________________________________________ |
Date ___________________________________________ |
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(MM/DD/YYYY) |
Telephone Number ( |
)_________________________________ |
Fax Number ( |
)________________________________ |
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.
12/09 |
7 |
73702 |
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
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 |
_______________ |
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(Signature) |
(Social Security Number — last 4 digits) |
(Date of Birth) |
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__________________________________________________ |
____________________________ |
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(Printed name of individual subject to this disclosure) |
(Date Signed) |
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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) |
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Authorization |
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Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.