Group Accidental Injury/Critical Illness Health Screening
and Wellness Visit Benefits - Proof of Loss
831644 06/2013
Connecticut General Life Insurance Company
Life Insurance Company of North America
Cigna Life Insurance Company of New York
Great - West Healthcare Administered by Cigna
Cigna
P.O. Box 55290
Phoenix, AZ 85078
1-800-754-3207 Toll Free
1-860-730-6460 Fax
E-mail Address:
accidentinjury/criticalillness@cigna.com
EMPLOYEE'S CERTIFICATION
831644 06/2013
Relationship to Employee
Dependent’s Occupation
YOUR CLAIM WILL BE SUBJECT TO DELAY OR RETURN IF THESE INSTRUCTIONS ARE NOT FOLLOWED.
No
TO BE COMPLETED IF CLAIM IS FOR DEPENDENT BENEFITS
To The Employee
A. For all benefits, complete pages 2 and 4 and review page 5.
B. If claiming Health Screening Benefits, please complete Section A on page 3.
C. If claiming Wellness Visit Benefits, please complete Section B on page 3.
D. Submit itemized bills for each health screening, wellness visit or preventative care.
THIS FORM IS FOR CRITICAL ILLNESS OR HEALTH SCREENING BENEFITS.
Name of Dependent (Last Name)
I CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT.
INSTRUCTIONS FOR FILING A CLAIM
( )
Address (Street) (City) (State) (Zip Code)
Yes
The issuance of this form is not an admission of the existence of any insurance nor does it recognize the
validity of any claim and is without prejudice to the Company’s legal rights.
Was the Dependent Disabled prior to the date of
the Health Screening or Wellness Visit?
If Yes, Date Disability began
SIGNATURE OF AUTHORIZED REPRESENTATIVE:
Date Signed
Page 2 of 5
Telephone #
SECTION TO BE COMPLETED BY THE EMPLOYEE FOR EMPLOYEE AND DEPENDENT BENEFITS
Name of Employee/Insured (Last Name)
Date of Birth
(First Name) (Middle Initial)
F
Address (Street)
(City) (State) (Zip Code)
Date Last Worked
Sex
M
Social Security No.
Employee’s Marital Status
Policy Number(s)
Telephone Numbers
Day Evening
Occupation
Hrs./Wk.
Part-time
Full-time
Domestic Partner Relationship
Hourly
Salaried
Widow/Widower
Single Married Separated
ManagementActive Exempt Supervisory Union Local #
Non-Union
Please check all of the boxes that apply to the employee’s employment status and job classification.
Non-SupervisoryNon-ManagementRetired Non-Exempt
Civil UnionDivorced
Date Hired/Member of Assoc.
Has an assignment been taken? (If so please attach.)
Were you an active Employee until the date of your Health Screening or Wellness Visit?
NoYes
If No, Please Explain
Yes
Unpaid Leave of AbsenceDisability (LTD)
Paid Leave of Absence FMLA
Other:
Discharged
Resigned
Vacation Sabbatical
Disability (STD) Temporary Layoff
If you were not actively at work, what was the reason?
Name & Address of School
Part-time student
Is Child
Full-time student
School Telephone Number
Dependent’s Employer
Dependent’s Employer’s Telephone Number
EMPLOYER'S CONTACT INFORMATION
Name of Employer / Association
E-Mail Address
No
CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1)
files an application for insurance or statement of claim containing any materially false information; or (2)
conceals for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent
insurance act. For residents of the following states, please see the last page of this form: California, Colorado,
District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New York, Oregon,
Pennsylvania, Rhode Island, Tennessee, Texas or Virginia.
SexSocial Security No.Date of Birth
(First Name) (Middle Initial)
Email Address
(Zip Code)(State)
(City)
FM
Do you have health care coverage with Cigna?
No
Yes
CLEAR FORM
Relationship to Employee:
Claimant Name (If other than Employee):
The issuance of this form is not the admission of the existence of any insurance nor does it recognize the
validity of any claim and is without prejudice to the company’s legal rights.
831644 06/2013
I CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE, CORRECT AND COMPLETE.
Signature of Claimant:
Date:
Name of Employee/Insured (Last Name)
Social Security No.
(First Name) (Middle Initial)
Page 3 of 5
SECTION B: (REQUIRED FOR ACCIDENTAL INJURY WELLNESS BENEFITS)
WHICH HEALTH SCREENING TEST DID THE CLAIMANT HAVE PERFORMED?
HEALTH SCREENING INFORMATION
Well Child Care - Visits, Labs and Immunizations
Routine gynecological exams
General health exams
Lead poisoning screening
Adult immunizations
Cancer screenings
Colorectal cancer screening
Routine prostate exams
Osteoporosis screenings
Please submit an itemized bill for each test or screening and any preventative care you or your dependent might have undergone.
Date
SECTION A: (REQUIRED FOR ACCIDENTAL INJURY/CRITICAL ILLNESS HEALTH SCREENING BENEFITS)
WHICH HEALTH SCREENING TEST DID THE CLAIMANT HAVE PERFORMED?
HEALTH SCREENING INFORMATION
Stress test on a bicycle or treadmill
CA 15-3 (Blood Test for Breast Cancer)
Hemocult Stool Specimen
Fasting Blood Glucose Test
CA 125 (Blood Test for Ovarian Cancer)
Bone Marrow Testing
PSA (Blood Test for Prostate Cancer)
Chest X-Ray
Serum Cholesterol Test (HDL AND LDL)
Colonoscopy
Serum Protein Electrophoresis (Myfloma)
Blood Test for Triglycerides
CEA (Blood Test for Colon Cancer)
Pap Smear (Women over age 18)
Flexible Sigmoidoscopy
Breast Ultrasound
Mammography
Thermography
Date
Date
Page 4 of 5831644 06/2013
Disclosure Authorization
AUTHORIZATION
I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health plan;
other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company,
reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity; the
Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability
Income Record System; government organization or agency, including the Social Security Administration; financial institution,
accountant or tax preparer; consumer reporting agency; and employer or group policyholder that has information about my health,
prescriptions,
financial, earnings or employment history, or other insurance claims and benefits to provide access to or copies of this
information to the Plan and to any individual or entity who provides services to or insurance benefits on behalf of the Plan, including
but not limited to the requesting company(ies) named below ("Company"). To the extent I may be eligible for governmental benefits
similar to or that coordinate with those available to me under the Plan, I also authorize disclosure of information necessary to apply for
or determine my eligibility for such benefits to the relevant government agency and/or vendor providing application assistance.
For any claim for insurance benefits, this authorization is valid for the shorter of 24 months or the duration of my claim. For all other
permitted disclosures, this authorization is valid for one (1) year from the date below. I am entitled to a copy of this authorization and a
photographic or electronic copy of it is as valid as the original.
I understand that any information obtained with this authorization will be used for evaluating and administering my coverage,
including any claim for benefits, or otherwise providing services related to or on behalf of the Plan, which may include, but is not limited
to assisting me in returning to work and Plan administration. With respect to governmental benefits similar to or that coordinate with
benefits available to me under the Plan, I understand that the information will be used to help determine my eligibility for any such
benefits and may include assisting me in applying for the benefits. I understand that the information disclosed under this authorization
is subject to redisclosure and may no longer be protected by certain federal regulations governing the privacy of health information,
although it will continue to be protected by other applicable privacy laws and regulations.
I understand that I do not have to give this authorization. If I choose not to give the authorization - or if I later revoke - I understand that
the Plan, insurers, or other providers of services or benefits related to the Plan who rely on this authorization may not be able to
evaluate or administer my request for Plan benefits, coverage or services and that my request for Plan benefits, coverage or services
may be denied as a result. I may revoke this authorization by sending written notice to the Claim Manager handling my claim.
Claimant’s Name:
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of drugs
or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.
NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer coverage and services
under your employer’s employee health and welfare plan(s) ("the Plan") and similar or coordinating governmental benefits. You are not
required to sign the authorization, but if you do not, the Plan, insurers or other providers of services or coverage under the Plan may not
be able to process your request for Plan benefits, coverage or services.
Company Names: Life Insurance Company of North America, Cigna Life Insurance Company of New York, Cigna Worldwide Insurance
Company, Great-West Life & Annuity Insurance Company, First Great-West Life & Annuity Insurance Company, New England Life
Insurance Company, Alta Health & Life Insurance Company and Connecticut General Life Insurance Company.
Guardian, or Conservator, please attach a copy of the document granting authority.
(Date of Birth)(Print Name)
(indicate relationship). If Power of Attorney Designee,I signed on behalf of the claimant as
(Claimant’s Signature) (Date Signed)
PRINT
Page 5 of 5
831644 06/2013
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
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance
within the department of regulatory agencies.
Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or
benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
Texas Residents: Any person who knowingly presents a 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.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an
insurer is guilty of a crime.
New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information
is subject to criminal and civil penalties.
New York 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 shall also be subject to a civil penalty not to exceed $5000 and the stated
value of the claim for each such violation.
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other
person: (1) files an application for insurance or statement of claim containing any materially false information; or,
(2) conceals for the purpose of misleading, information concerning any material fact, may have committed a
fraudulent insurance act.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against
an insurer, submits application or files a claim containing a false or deceptive statement may have violated state
law.
District of Columbia 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.
Kentucky Residents: 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.
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.
Maryland Residents: 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.
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.
Tennessee 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 include imprisonment, fines and denial
of insurance benefits.
California Residents: Any person who knowingly presents a 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.
IMPORTANT CLAIM NOTICE
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