Disability Claim Form – Fill Out and Use This PDF

Filling out a disability claim form is crucial to getting the help you need. Your paperwork should be filled with declarations that prove your disability and why you are deserving of financial aid.

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Disability Claim Form PDF Details

When you are injured or become ill, it is often necessary to file a disability claim with your insurance company. The process of filing a disability claim can seem daunting, but with the right information and resources, it can be easy to complete. This guide will provide you with everything you need to know about filing a disability claim form. From what information is required to how to submit the form, we have you covered.

These are some specifics about disability claim form. You may learn its length, the average time to fill out the form, the blanks you should fill in, etc.

Question	Answer
Form Name	Disability Claim Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	colonial life disability claim insurance form, colonial life continuing disability form, colonial continuing form, colonial life continuing claim form

Form Preview Example

Colonial Life & Accident Insurance Company, Columbia, SC | CONTINUING DISABILITY | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Continuing Disability Claim

FAX this direction

FAX this form: 1-800-880-9325

Or mail: P.O. Box 100195, Columbia, SC 29202

From:

Number of pages:

Submit Additional Information Online

uSimply log into your account at Coloniallife.com and click on the claim number to add additional information. You will be able to upload the form after it has been completed by the employer and/ or the physician.

uIf you did not select direct deposit when you initially submitted the claim, go to the My Proﬁle page on your account and select direct deposit. You will also need to call our Contact Center to have the information added to the current claim.

uNot a member? Log onto Coloniallife.com and click on "Register" then "Join the Policyholder Website" to set up your account.

Optional Service Release Agreement

Please indicate below for optional services you desire. Any marks used (check mark, X, initials, etc.) will be considered as your authorization and will be processed as if they were selected.

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

______ Sales representative ______ Employer ______ Spouse, family member or signiﬁcant other Name: _________________________

______ I want Colonial Life to update me on the status of my claim through prerecorded messages at my contact number indicated on this

form. I understand that messages will be left with anyone who answers the phone or on my answering machine. Note: To avoid blocked calls, you should program the number 1-800-325-4368 into your 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.

I also understand that if I want my claim to be sent by overnight delivery, a $22.00 fee will be deducted from my claim payment. This fee is subject to rate increases by carrier and does not include weekend or holiday delivery. I understand that Colonial Life is unable to send overnight mail to a P.O. Box.

I also understand that I must notify Colonial Life to discontinue any of these services.

Do not use this form if ﬁling for injury or sickness for the ﬁrst time.

Complete each section before submitting your claim. Incomplete claim form submission may result in a delay in the processing of your claim.

Please make sure that all written responses are legible.

Section 1 – Claimant statement (completed by policy owner)

Claimant name:

£Male £Female

DOB: ____ /____ /______

SSN:

Relationship to policy owner: £Self £Spouse		£Domestic partner £Dependent


Policy owner information	Name:				DOB: ____ /____ /______		SSN:
(if other than claimant)	Name:				DOB: ____ /____ /______		SSN:
(if other than claimant)
Address:			Apt. #	City:		State:		ZIP:

Email:					Contact number:
Email:					Home/Cell/Work
					Home/Cell/Work

Claim is for: £Accident £Sickness			Date the accident occurred (not when it was treated): ______ /______ /_________

Condition that keeps you from working:

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

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.

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneﬁt or who knowingly present false information in an application for insurance is guilty of a crime and may be subject to restitution ﬁnes or conﬁnement in prison, or any combination thereof.

Arizona: 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, Rhode Island, Texas and West Virginia: For your protection, California, Rhode Island, 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: 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: 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: 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: 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.

Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or beneﬁt or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to ﬁnes and conﬁnement in prison.

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.

New York: 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 shall also be subject to a civil penalty not to exceed ﬁve thousand dollars and the stated value of the claim for each such violation.

Pennsylvania: 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

Puerto Rico: 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 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 1 – Claimant statement ~ continued (completed by policy owner)

Have you been unable to work?: £ Yes £ No If yes, list the dates unable to work: From: _______ / _______ / ________ To: _______ / _______ / ________

Date returned to work: Full-time: ______ / _______ / _________ Part-time: ______ / _______ / _________ Hours worked per week: ____________

If not employed

List dates of house conﬁnement: From: ______ / _______ / _________ To: ______ / _______ / _________

House conﬁnement means you are kept at home (in house or yard) by the condition. However, you may follow physician's orders, even if it means leaving home.

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

Certiﬁcation

Policy owner’s name: _________________________________________________________________________ SSN: _________________________

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 two 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.

____________________________________________________	____________________________________________________	______________________________
Print claimant’s name	Claimant’s signature	Date
____________________________________________________	____________________________________________________	______________________________
Print policy owner’s name	Policy owner’s signature	Date

Section 2 – Employer statement (completed by employer)

Employee name:							Employee title:

Average number of scheduled hours per week:			Date last worked: _____ / _____ / ________					Date employment terminated: _____ / _____ / ________
			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

How to Edit Disability Claim Form Online for Free

With the goal of making it as effortless to use as it can be, we generated our PDF editor. The procedure of filling the colonial life claim forms printable template can be easy for those who keep to the following steps.

Step 1: To start out, choose the orange button "Get Form Now".

Step 2: So, it is possible to edit the colonial life claim forms printable template. The multifunctional toolbar makes it easy to include, remove, transform, highlight, and also undertake other commands to the words and phrases and areas within the file.

In order to obtain the form, type in the data the system will require you to for each of the appropriate segments:

colonial life disability claim insurance form spaces to complete

Provide the demanded information in form I understand that messages, Yes I want ALL payments for this, I also understand that if I want, I also understand that I must, Do not use this form if ﬁling for, Section Claimant statement, Claimant name, Male Female, DOB, SSN, Relationship to policy owner Self, Policy owner information if other, Name, DOB, and SSN field.

stage 2 to entering details in colonial life disability claim insurance form

You should be requested for specific key particulars to be able to fill out the Address, Email, Apt, City, State, ZIP, Contact number HomeCellWork, Claim is for Accident Sickness, Date the accident occurred not, Condition that keeps you from, Colonial Life insurance products, and ColonialLifecom section.

colonial life disability claim insurance form Address, Email, Apt, City, State, ZIP, Contact number HomeCellWork, Claim is for Accident Sickness, Date the accident occurred not, Condition that keeps you from, Colonial Life insurance products, and ColonialLifecom fields to fill out

The Colonial Life Accident Insurance, Claimant name, Claimant SSN, Section Claimant statement, Have you been unable to work Yes, Date returned to work Fulltime, If not employed List dates of, Have you been unable to perform, Certiﬁcation Policy owners name, and I have checked the answers on this field enables you to specify the rights and obligations of either side.

Filling in colonial life disability claim insurance form part 4

Look at the sections I have checked the answers on this, Print claimants name, Claimants signature, Date, Print policy owners name, Policy owners signature, Date, Section Employer statement, Employee name, Employee title, Average number of scheduled hours, Date last worked, Date employment terminated, Was the employee at work when, and Was a workers compensation claim and next fill them in.

colonial life disability claim insurance form I have checked the answers on this, Print claimants name, Claimants signature, Date, Print policy owners name, Policy owners signature, Date, Section Employer statement, Employee name, Employee title, Average number of scheduled hours, Date last worked, Date employment terminated, Was the employee at work when, and Was a workers compensation claim blanks to fill out

Step 3: Hit the "Done" button. You can now upload the PDF document to your gadget. As well as that, you'll be able to deliver it through email.

Step 4: Try to make as many duplicates of your document as possible to avoid future troubles.

Disability Claim Form – Fill Out and Use This PDF

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