Form Esg P0 55595 PDF Details

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QuestionAnswer
Form NameForm Esg P0 55595
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesCancer Int Care Claim Form form esg p055595

Form Preview Example

Professional Insurance Company

In California, PIC Life Insurance Company

 

 

 

 

 

 

P.O.BOX 85656

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LINCOLN,NE 68501-5656

 

 

800-289-1122

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ClaimNo.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PolicyNos.

 

 

 

 

 

 

 

 

 

 

 

 

 

CLAIMANT’SSTATEMENT: Completeforallclaims.ForCancerPolicy,pleasesubmitPathologyReport.

Policyholder’sName

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DateofBirth

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HomePhone(

)

 

 

 

 

 

 

 

SocialSecurityNo.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dependent’sName

 

 

 

 

 

 

 

Relationship

 

 

 

DateofBirth

 

 

 

 

Answerif

 

 

 

 

 

 

 

 

 

 

 

 

 

 

claimison

 

 

Isdependentemployed?Yes

No

Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

dependent

 

 

Isdependentastudent? Yes

No

School

 

 

 

 

 

 

 

DependentSS#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

CLAIMISFORAccident

Illness

Natureofillness/injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Dateofaccidentor1st signofillness

 

 

 

 

 

 

 

 

Ifclaimisforanaccident,describehowandwhereit

 

 

occurred:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

HasclaimbeenmadeorwillclaimbemadeunderanyWorker’sCompensationorEmployersLiabilityLaw?Yes

 

No

4.

Wereyouhospitalized? Yes

No

 

 

Ifyes,givedates,from

 

 

 

 

to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mo Day Yr

 

 

 

 

Mo DayYr

 

 

 

Name/AddressofHospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ifyouwerehospitalized,pleasesendacopyofthehospitalbill.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

ListallDoctorsyouhaveseenforthiscondition.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

Date1stseen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Haveyoueverhadsymptomsofthisconditionbefore?

Yes

No

 

 

When

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

DoyouhaveinsurancewithanyotherCompany?

Yes

No

 

 

Ifyes,provide

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NameofCompany

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PolicyNumber(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT:PLEASESUBMITACOPYOFTHEPOLICEREPORTIFTHISCLAIMISDUETOAVEHICLEACCIDENT.

CompletethisSectiononlyifyouarefilingfordisability(lossoftimefromwork)benefits.

 

 

 

 

 

 

 

 

1.

Dateyoustoppedworkingduetodisability_________________Dateyoureturned,orwillreturn,towork

 

 

 

 

2.

Areyouconfined(restrictedbyDrs.orders)toyourhome? Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

3.

AverageMonthlyEarnings$__________

4.ListJobDuties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER’SSTATEMENT:Mustbecompletedfordisabilitybenefits.

 

 

 

 

 

 

 

 

 

 

 

 

1.

Dateoffirstabsenceduetodisability____________________DateEmployeereturnedtowork

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

MonthlyEarnings

 

 

 

 

Datehired

 

 

 

 

 

 

 

 

Dateoftermination,if terminated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

HasclaimorwillclaimbemadeforWorker’sCompensationBenefits?

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Ifyes,whatisstatusofclaim?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.Willyouprovide“lightduty”ifemployeeisreleasedwithrestrictions?Yes

No

 

 

 

 

 

 

 

 

NameofEmployer

 

 

 

 

 

 

 

 

 

 

 

PhonenumberofEmployer (

)

 

 

 

 

 

 

 

AuthorizedSignature________________________________________TitleorPosition___________________Date

 

 

 

 

AUTHORIZATION TO OBTAIN INFORMATION: I hereby authorize any physician or practitioner of the healing arts who has examined or treated me, and all hospitals, clinics or medically related facilities, insurance companies, health maintenance organizations, medical information bureau, government entity (federal, state or local) or other organization, institution or person, that has any information, records or knowledge of me or my health, past or present, to furnish to Professional Insurance Company (or its representatives) and to permit them to examine and copy any such information. I understand that Professional Insurance Company may disclose the information in connection with underwriting or claims processing with the company. A copy of this authorization, or the original, shall be valid for ninety (90) days from the date signed. I acknowledge that I have a right to a copy of this authorization upon request.

ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD OR DECEIVE ANY INSURANCE COMPANY FILES A STATEMENT OF

CLAIM CONTAINING ANY MATERIALLY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF COMMITTING A

FRAUDULENT INSURANCE ACT WHICH IS A CRIME AND SUBJECT TO CRIMINAL PROSECUTION.

ClaimantSignature_______________________________________ Date

ESG-P055595(08/01)

THISCLAIM REPORTIS USEDFOR ANY TYPEOFHEALTH CLAIM ANDMUST BERETURNED TO

PROFESSIONAL INSURANCE COMPANY, P.O.BOX 85656, LINCOLN,NE 68501-5656 PHONE 800-289-1122

PARTA TOBECOMPLETED BYPATIENT (INSURED)

PATIENT’S NAME ANDADDRESS

INSURED’SNAME ANDADDRESS IFPATIENT IS ADEPENDENT

AUTHORIZATION TORELEASE INFORMATION: I HEREBYAUTHORIZE

 

SIGNED(PATIENT, ORPARENT IF MINOR)

THEUNDERSIGNED PHYSICIAN TO RELEASE ANYINFORMATION

 

 

ACQUIRED INTHE COURSE OF MY EXAMINATION OR TREATMENT.

 

DATE

 

 

 

 

 

PARTB

ATTENDINGPHYSICIAN’S STATEMENT

 

 

Forroutine FIRST-AIDclaims, thisside isnotusually required, ifa copyofthe billshowing Patient’s name, diagnosis,charges, anddate incurred is furnishedalong withClaimant’s Statement onreverse side.

1. DIAGNOSISAND CONCURRENT CONDITIONS

(IFDIAGNOSIS CODE OTHER THAN ICDA USED,GIVE NAME)

2.ISCONDITION DUE TO INJURY ORSICKNESS ARISING OUTOFPATIENT’S EMPLOYMENT? YES NO

3.IFCONDITION IS DUE TOACCIDENT, PLEASE GIVE DETAILS OF ACCIDENT.

4.ISCONDITION DUE TO PREGNANCY? YES

NO

IFYES,EXPECTED DATE OF DELIVERY

 

DATE OF LMP

5.REPORTOF SERVICES (OR ATTACH ITEMIZED BILL).IF APREVIOUS FORMHAS BEEN SUBMITTED TOTHISCARRIER, YOU

NEEDSHOW ONLY DATESAND SERVICES SINCE LAST REPORT.

Dateof

 

 

 

 

 

ProcedureCode–

Services

 

Placeof

 

 

 

Ifused(Ifcodeother

(Mo.Day,Yr.)

 

Services

 

DescriptionofSurgicalorMedical ServicesRendered

 

thanCPTused,givename)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. DATESYMPTOMS FIRST APPEARED ORACCIDENT HAPPENED.

7. DATEPATIENT FIRST CONSULTED YOUFOR THISCONDITION.

 

 

 

 

 

 

 

8. HASPATIENT EVER HADSAME ORSIMILAR CONDITION?

9. PATIENT STILLUNDER YOURCARE FOR THISCONDITION?

YES

NO

IF“YES” WHEN AND DESCRIBE:

YES

NO

IFNO, DATE LAST SEEN

 

 

 

 

 

 

 

 

 

 

10. PATIENTWASCONTINUOUSLY TOTALLY DISABLED

11.PATIENT WAS PARTIALLY DISABLED (ABLE TO PERFORM SOME

(UNABLE TOPERFORM SUBSTANTIALLY ALL OFHIS/HER

BUTNOT ALL OF HIS/HER OCCUPATIONAL DUTIES)

 

 

 

 

OCCUPATIONAL DUTIES)

 

 

 

 

 

 

 

 

 

FROM

 

THROUGH

FROM

 

THROUGH

 

 

 

 

12. IFSTILLDISABLED, DATE PATIENT SHOULD BE ABLE

13. PATIENT WASHOSPITAL CONFINED: FROM

 

TO

 

 

TORETURN TOWORK.

PATIENTWASHOUSE CONFINED: FROM

 

TO

 

 

 

 

 

(HOUSECONFINEMENTISTHEINABILITY TOLEAVETHE HOUSEEXCEPTTO OBTAIN

 

 

 

MEDICALTREATMENTORTOENGAGEIN MEDICALYPRESCRIBEDACTIVITIES THAT

 

 

 

ARE THERAPEUTICINNATURE.)

 

 

 

 

 

 

14. DOESPATIENT HAVE OTHER HEALTHCOVERAGE?

15. WASPATIENT REFERRED TOYOU BYANOTHER PHYSICIAN?

IF“YES” PLEASE IDENTIFY

YES

NO

IF YES,PLEASE PROVIDE NAME OF REFERRING

 

 

 

PHYSICIAN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN’SNAME (PLEASE PRINT)

 

 

 

IRSIDENTIFICATION NO.*

 

 

 

PHYSICIAN’SSIGNATURE ________________________________________________________ DEGREE __________________________ DATE

 

 

ADDRESS

 

 

 

 

 

 

 

 

Street

City

StateorProvince

Zip

Phone Number (w/area code)

FaxNumber (w/area code)

*THE INSERTION OF THE IRS NUMBER IS REQUIRED BYTHE INTERNAL REVENUE SERVICE.

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