Disability Claim Form – Fill Out and Use This PDF

Relationship to policy owner: £Self £Spouse

£Domestic partner £Dependent

Policy owner information

Name:

DOB: ____ /____ /______

SSN:

(if other than claimant)

Address:

Apt. #

City:

State:

ZIP:

Email:

Contact number:

Home/Cell/Work

Claim is for: £Accident £Sickness

Date the accident occurred (not when it was treated): ______ /______ /_________

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

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| ColonialLife.com | 7-20 | 46988-28

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

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| ColonialLife.com | 7-20 | 46988-28

Have you been unable to perform activities of daily living? £Yes £No

If yes, list dates: From: ______ / _______ / _________ To: ______ / _______ / _________

Check activities of daily living that you are unable to perform: £Dressing

£Eating £Meal preparation £Bathing £Transferring £Toileting £Continence

____________________________________________________

____________________________________________________

______________________________

Print claimant’s name

Claimant’s signature

Date

____________________________________________________

____________________________________________________

______________________________

Print policy owner’s name

Policy owner’s signature

Date

Employee name:

Employee title:

Average number of scheduled hours per week:

Date last worked: _____ / _____ / ________

Date employment terminated: _____ / _____ / ________

Was the employee at work when accident or sickness occurred? £Yes £No

Was a workers’ compensation claim filed? £Yes £No

Workers’ compensation carrier:

Telephone:

Employee unable to work (Full-time): From:________ / _______ / ___________ To: ________ / _______ / ___________

Do you permit light duty for employee? £Yes £No

Do you permit partial duty for employee? £Yes £No

Actual return to work

Actual return to work

Expected return to work: _______ / ______ / ________

Full-time: _______ / ______ / ________

Part-time: _______ / ______ / ________ Hours per week:________

Employee’s

£ Sitting _____ per hr. £ Walking _____ per hr. £ Climbing stairs/ladders _____ per hr. £ Standing _____ per hr. £ Driving _____ hrs. per day

duties

include:

Lifting: £ Less than 15 lbs. £ 15 to 44 lbs. £ More than 45 lbs.

Stooping/bending: £ none £ seldom £ frequent

Contact for updates on return to work status:

Telephone:

Email:

Fraud warning: Any person who knowingly files a statement of claim containing false or misleading information is subject to

criminal and civil penalties. This includes employer’s portions of the claim form.

______________________________________________________________________________________________________

______________________________

Signature of authorized person

Date (MM/DD/YYYY)

Title of authorized person signing:

Employer/company name:

Telephone:

Fax:

Email:

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

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| ColonialLife.com | 7-20 | 46988-28

Colonial Life & Accident Insurance Company, Columbia, SC | CONTINUING DISABILITY |

Fax: 1-800-880-9325

| Telephone: 1-800-325-4368

Claimant name:

Claimant SSN:

Section 3 – Physician statement (completed by physician)

Patient name:

DOB: _____ / _____ / _______

Is condition due to an accidental injury? £Yes £No

What diagnosis prevents the patient from working? (If pregnancy, list complications.)

Date first treated for this diagnosis:

______ / ______ / ________

Are there any secondary diagnoses preventing the patient from working? £Yes £No

Secondary diagnoses:

When did symptoms first appear?

Date of new patient consultation:

Symptoms:

______ / ______ / _________

______ / ______ / _________

Current treatment plan:

List any test performed (submit copy of test results):

List any surgeries performed (submit copy of operative report):

Date: _________ / _________ / ___________

CPT code: ________________

Date: _________ / _________ / ___________

CPT code: ________________

Date: _________ / _________ / ___________

CPT code: ________________

Date: _________ / _________ / ___________

CPT code: ________________

Date of patient’s last visit:

Date of next scheduled visit:

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

______ / ______ / _________

______ / ______ / _________

£1 - 2 months

£3 - 4 months

£5 - 6 months

£more than 6 months

Does patient have permanent restrictions and/or limitations? £Yes £No

Limitations (patient CANNOT DO):

Restrictions (patient SHOULD NOT DO):

If yes, which ones are permanent:

Dates unable to work (full-time):

From: _____ / ______ / ________

To: _____ / ______ / ________

Expected return to work: _____ / ______ / ________

Dates able to work (part-time):

From: _____ / ______ / ________ To: _____ / ______ / ________

Number of hours: ___________

Actual return to work (full time): _____ / ______ / ________

Did this condition require house confinement?: £Yes £No

If yes, From: ______ / ______ / _________ To: ______ / ______ / _________

House confinement means the patient is kept at home (in house or yard) by the condition. However, the patient may follow your orders, even if it means leaving home.

Check activities of daily living that the patient is unable to perform: £Dressing

£Eating £Meal preparation

£Bathing

£Transferring £Toileting £Continence

Dates unable to perform activities of daily living: From: _____ / _____ / ________

To: _____ / _____ / ________

Date(s) of hospitalization (last 3 months):

Date(s) of office visit (last 3 months):

Have you referred patient to a specialist? £Yes £No

Hospital:

Specialist:

Address:

State:

ZIP:

Address:

State:

ZIP:

Telephone:

Fax:

Telephone:

Fax:

PREGNANCY

Date of delivery: _______ / _______ / __________

Type of delivery: £Vaginal

£C-section

Fraud warning: 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.

_________________________________________________________________________________________

___________________________________

Physician signature

Date (MM/DD/YYYY)

Physician/group name:

Patient account number:

Physician’s specialty:

Telephone:

Fax:

Address:

City:

State:

ZIP:

Tax ID or SSN:

Do you accept medical record requests by fax?

£Yes £No

Do you require a special authorization for release of information? £Yes £No

Patient Portal £Yes £No

Will you accept the standard HIPAA release?

£Yes £No

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

Authorization on file to release information to Colonial Life: £Yes

£No

Referring physician:

Telephone:

Fax:

Address:

City:

State:

ZIP:

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

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| ColonialLife.com | 7-20 | 46988-28