Fillable Claims Made Easy Your claim is processed ten (Combined Insurance)

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Claims Made Easy Your claim is processed ten (Combined Insurance)

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FILING A CLAIM BY MAIL
1. Download the claim form.
2. Print all pages of the claim form.
3. Complete all sections of the Claimant Statement.
4. If you are claiming disability, have your employer complete and sign the Employer’s
Statement found in SECTION C on the third page.
5. Have your physician complete SECTION D, the Attending Physician’s Statement, on
the fourth page.
6. Review the Fraud Notification for your state on the fifth or sixth page.
7. Sign and date the claim form on the signature line provided at the end of the Fraud
Notification page of the claim form. If you do not sign the Fraud Notification page, we
cannot accept your claim submission.
8. Elect to receive documents electronically and, if your claim is payable, opt in to
receive your benefit payment sent electronically via bank transfer into a checking
account, transfer into a PayPal account, or transfer to a debit card (as available).
To authorize this, please complete and sign the Consent to Electronic Transactions,
Payments and Signature document.
9. Sign and date the Authorization to Obtain and Disclose Health Information.
10. Send your signed, completed claim form with the Attending Physician’s Statement,
Employer Statement, if applicable, and any medical bills or documentation that you
may have related to your accident or illness to:
Combined Insurance Claim Department
PO Box 6700
Scranton, PA 18505-0700
Claims Made Easy
Your claim is processed ten days faster* when you submit a claim online
at www.CombinedInsurance.com/Claims
* On average
Combined Insurance Company of America | Chicago, IL
WSRCE-1 (0420)
Accident: For loss due to an accidental bodily injury, please complete the Accident section of
the form including a detailed description of how the accident occurred.
Sickness: If filing for loss due to sickness, fill in the section of the form relating to symptoms
and diagnosis. You may be requested to provide additional details regarding medical
treatment you received within the 5 years prior to your policy eective date.
Critical Illness: If filing a critical illness claim, please fill in the date of diagnosis and provide a
copy of the pathology report or test results confirming the diagnosis and the level of severity.
Hospitalization: If hospitalized, provide us with the name and address of the hospital including
the admission and discharge dates. Please also send a copy of the itemized hospital bill
including the number of days you were an inpatient.
Disability: If you were disabled and have disability coverage, give the exact dates of the total
and/or partial disability. If you are still disabled at the time you submit your claim form, another
claim form will be sent to you for continuing disability.
Wellness: If filing for wellness/preventative/health screening benefits, please review your
policy carefully to ensure the test or procedure is covered under your policy. Do not use the
attached claim form if filing for wellness or health screening benefits. Rather use the Health
and Wellness claim form which can be found at www.combinedinsurance.com/forms.
HELPFUL TIPS:
First page (Claimant completes)
Please include your complete name and current mailing address on the claim form as any payment
and/or correspondence will be sent to the address indicated on the claim form. Indicate your policy
numbers/certificate numbers on the claim form; this will help us respond quicker.
Additional: Please be sure to sign and date the Authorization to Release Information. This will
prevent unnecessary delays in the event additional information is needed.
Third page (Employer completes)
If you are employed outside the home, your employer must verify your disability by completing
Section C – Employer’s Statement. Please note: If the insured is a student, the school principal should
complete this section.
Fourth page (Doctor completes)
Your primary physician must complete Section D – Attending Physician’s Statement in its entirety.
Failure to make sure that your physician fills in all necessary information on the claim form may cause
delays in the processing of your claim.
For your records, we suggest that you keep a copy of the completed claim form and any bills you
submit. Note the date mailed. Mail all pages of the completed form and any enclosures to:
Combined Insurance Claim Department
P O Box 6700, Scranton, PA 18505-0700
* On average
Remember, your claim is processed ten days faster* when you submit a claim online at
www.CombinedInsurance.com/Claims
Combined Insurance Company of America | Chicago, IL
Claims Made Easy
WSRCE-1 (0420)
PLEASE LIST OTHER NAMES THAT YOU MAY USE SUCH AS MAIDEN NAME, NICKNAME, ETC. PRIMARY PHONE
SECONDARY PHONE
MAILING ADDRESS
CITY STATE ZIP
SOCIAL SECURITY # (LAST 4 DIGITS) BIRTH DATE (MM/DD/YYYY)
/ /
HEIGHT (FT/IN) WEIGHT (LBS)
MALE FEMALE
POLICY/CERTIFICATE NUMBER(S)
EMPLOYER’S NAME
EMPLOYER’S CONTACT NAME EMPLOYER’S CONTACT PHONE NUMBER
EMPLOYER’S CONTACT FAX NUMBER
IF YOU HAVE OTHER ACCIDENT-SICKNESS DISABILITY INSURANCE, GIVE COMPANY NAME, ADDRESS, AND BENEFIT AMOUNT. (IF NONE, STATE “NONE”)
YOUR OCCUPATION MONTHLY EARNINGS
$
,
BRIEFLY DESCRIBE YOUR OCCUPATIONAL DUTIES
HAVE YOU FILED A CLAIM UNDER THE FOLLOWING:
WORKERS’ COMPENSATION
ACT? YES
NO
SOCIAL SECURITY
ACT? YES
NO
STATE DISABILITY
BENEFITS? YES
NO
IF YES TO ANY OF THE PRECEDING,
PLEASE SUBMIT A COPY OF THE AWARD
OR DENIAL LETTER IF RECEIVED.
FIRST NAME LAST NAME M.I.
IMPORTANT INSTRUCTIONS FOR FILING CLAIM
1. USE THIS CLAIM FORM FOR ALL CLAIMS EXCEPT FOR WELLNESS/PREVENTATIVE/HEALTH SCREENING BENEFITS.
2. IF DISABILITY IS CLAIMED, PLEASE HAVE YOUR EMPLOYER OR SCHOOL COMPLETE SECTION C, THE EMPLOYER’S STATEMENT.
3. IF MEDICAL OR HOSPITAL BENEFITS ARE CLAIMED, ITEMIZED BILLS MUST BE ATTACHED.
SECTION A CLAIMANT STATEMENT
PLEASE PRINT
Statements made by you on this claim form must be true and complete. Please review the Fraud Warning for your state
on the attached Fraud Notication pages. You must sign and date this claim form on the signature line provided on the
Fraud Notications page. If you do not sign this Fraud Notications page, we cannot accept your claim submission.
WSRCE-1 (0420)
E-MAIL ADDRESS (Your e-mail address will be updated with this information if different from the e-mail on le)
EMPLOYER’S ADDRESS
CITY STATE ZIP
COMPANY NAME
ADDRESS
CITY STATE ZIP
BENEFIT AMOUNT
WEEKLY
$
,
BI-WEEKLY
$
,
MONTHLY
$
,
Combined Insurance Company of America
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-800-544-9382 • Fax 312-351-6930
PHONE NUMBER
FAX NUMBER
ADMISSION DATE (MM/DD/YYYY)
/ /
DISCHARGE DATE (MM/DD/YYYY)
/ /
WSRCE-1 (0420)
TOTAL DISABILITY:
BETWEEN WHAT DATES WERE YOU UNABLE TO PERFORM ANY DUTIES?
PARTIAL DISABILITY:
BETWEEN WHAT DATES WERE YOU ABLE TO PERFORM ONLY PARTIAL DUTIES?
FROM (MM/DD/YYYY)
/ /
THROUGH (MM/DD/YYYY)
/ /
FROM (MM/DD/YYYY)
/ /
THROUGH (MM/DD/YYYY)
/ /
DATE LAST WORKED (MM/DD/YYYY)
/ /
DATE RETURNED TO WORK (MM/DD/YYYY)
/ /
PLEASE HAVE YOUR EMPLOYER COMPLETE AND SIGN SECTION C - EMPLOYER’S STATEMENT FOUND ON THE NEXT PAGE. IF THE INSURED IS A STUDENT, THE
SCHOOL PRINCIPAL SHOULD COMPLETE THIS SECTION.
COMPLETE FOR DISABILITY CLAIM
COMPLETE FOR EITHER ACCIDENT OR SICKNESS CLAIM
DATE OF DIAGNOSIS FOR CURRENT SICKNESS
(MM/DD/YYYY)
/ /
SICKNESS DIAGNOSIS IF KNOWN
IF FILING FOR CRITICAL ILLNESS BENEFITS, PLEASE ATTACH A COPY OF THE PATHOLOGY REPORT OR TEST(S) THAT CONFIRM THE DIAGNOSIS AND THE SEVERITY OF THE CONDITION.
COMPLETE FOR SICKNESS CLAIM
PLEASE PROVIDE ADDITIONAL DETAILS INCLUDING SYMPTOMS.
SECTION B CLAIMANT STATEMENT
PLEASE COMPLETE ALL APPLICABLE SECTIONS BELOW AND SUBMIT DOCUMENTATION TO SUBSTANTIATE COVERED SERVICES CLAIMED UNDER YOUR POLICY.
DATE OF ACCIDENT (MM/DD/YYYY)
/ /
INJURIES SUSTAINED
PLEASE PROVIDE AN EXACT DESCRIPTION OF WHERE YOU WERE WHEN ACCIDENT OCCURRED INCLUDING A DETAILED DESCRIPTION OF WHAT HAPPENED TO YOU.
COMPLETE FOR ACCIDENT CLAIM
HOSPITAL NAME
HOSPITAL ADDRESS
CITY STATE ZIP
PHONE NUMBER
FAX NUMBER
INITIAL DATE OF TREATMENT (MM/DD/YYYY)
/ /
LAST DATE OF TREATMENT (MM/DD/YYYY)
/ /
FIRST ATTENDING PHYSICIAN’S NAME
ADDRESS
CITY STATE ZIP
PHONE NUMBER
FAX NUMBER
INITIAL DATE OF TREATMENT (MM/DD/YYYY)
/ /
LAST DATE OF TREATMENT (MM/DD/YYYY)
/ /
SECOND ATTENDING PHYSICIAN’S NAME
ADDRESS
CITY STATE ZIP
EMPLOYEE’S FIRST NAME LAST NAME M.I.
SECTION C
EMPLOYER’S STATEMENT
DATE LAST WORKED (MM/DD/YYYY)
/ /
DATE RETURNED TO WORK (MM/DD/YYYY)
/ /
FULL TIME
PART TIME
MONTHLY EARNINGS
$
,
EMPLOYEE’S OCCUPATION DESCRIPTION OF OCCUPATION’S PRIMARY DUTIES
WORKERS’ COMPENSATION CLAIM FILED FOR THIS DISABILITY? YES
NO
PAID? YES
NO
PHONE NUMBER
TOTAL DISABILITY:
BETWEEN WHAT DATES DID THE EMPLOYEE NOT PERFORM ANY JOB DUTIES?
PARTIAL DISABILITY:
BETWEEN WHAT DATES DID THE EMPLOYEE ONLY PERFORM PARTIAL JOB DUTIES?
FROM (MM/DD/YYYY)
/ /
THROUGH (MM/DD/YYYY)
/ /
FROM (MM/DD/YYYY)
/ /
THROUGH (MM/DD/YYYY)
/ /
DURING PARTIAL DISABILITY, DID/WILL EMPLOYEE RECEIVE 75% OR MORE OF HIS PRE-DISABILITY INCOME? YES
NO
IF NO, WHAT PERCENTAGE? ____________ %
DESCRIPTION OF DUTIES PERFORMED (IF ON PARTIAL DISABILITY)
EMPLOYER CONTACT NAME CONTACT’S POSITION DATE (MM/DD/YYYY)
/ /
SIGNATURE PHONE NUMBER
FAX NUMBER
IF YOU ARE EMPLOYED OUTSIDE THE HOME, YOUR EMPLOYER MUST VERIFY YOUR DISABILITY BY COMPLETING SECTION C – EMPLOYER’S STATEMENT. PLEASE NOTE: IF THE INSURED
IS A STUDENT, THE SCHOOL PRINCIPAL SHOULD COMPLETE THIS SECTION.
NAME
ADDRESS
CITY STATE ZIP
POLICY NUMBER(S)
CITY STATE ZIP
PHONE NUMBER
BIRTH DATE (MM/DD/YYYY)
/ /
CLAIM NUMBER (IF AVAILABLE)
WSRCE-1 (0420)
IF YES PROVIDE THE NAME, ADDRESS AND TELEPHONE NUMBER OF COMPENSATION CARRIER. ALSO, SEND REPORT OF INITIAL INJURY.
PHYSICAL JOB DEMANDS (HH = hours, MM = minutes)
SITTING
PER DAY WALKING
PER DAY CLIMBING STAIRS/LADDERS
PER DAY DRIVING
PER DAY
LIFTING:
LESS THAN 15LBS
15 TO 45LBS
MORE THAN 45LBS STOOPING/BENDING:
NONE
SELDOM
FREQUENT
H H M M H H M M H H M M H H M M
WSRCE-1 (0420)
HAS PATIENT EVER HAD SAME
OR SIMILAR CONDITION? YES
NO
(IF “YES”, STATE WHEN AND DESCRIBE.) (MM/DD/YYYY)
/ /
HOW DID CONDITION ORIGINATE? DESCRIBE ANY OTHER DISEASE OR INFIRMITY AFFECTING PRESENT CONDITION.
NATURE OF SURGICAL OR OBSTETRICAL PROCEDURE(S), IF ANY. (DESCRIBE FULLY)
DATE (MM/DD/YYYY)
/ /
PROCEDURE
NAME OF
FACILITY
OPEN OR CLOSED REDUCTION
OPEN
CLOSED
OFFICE DATE (MM/DD/YYYY)
/ /
/ /
/ /
NATURE OF
TREATMENT(S)
NAME OF
FACILITY
EMERGENCY
ROOM (ER)
DATE (MM/DD/YYYY)
/ /
NATURE OF
TREATMENT
NAME OF
FACILITY
URGENT
CARE
FACILITY
DATE (MM/DD/YYYY)
/ /
NATURE OF
TREATMENT
NAME OF
FACILITY
GIVE DATES OF TREATMENT AND NATURE OF TREATMENT OTHER THAN SURGICAL.
IS THE PATIENT STILL
UNDER YOUR CARE?
HOW LONG WAS OR WILL PATIENT BE CONTINUOUSLY TOTALLY DISABLED
(UNABLE TO WORK)?
HOW LONG WAS OR WILL PATIENT BE PARTIALLY DISABLED?
(ONLY ABLE TO WORK PART TIME OR PERFORM PARTIAL JOB DUTIES)?
YES
NO
FROM (MM/DD/YYYY)
/ /
THROUGH (MM/DD/YYYY)
/ /
FROM (MM/DD/YYYY)
/ /
THROUGH (MM/DD/YYYY)
/ /
PLEASE STATE RESTRICTIONS PLACED ON PATIENT FOR ANY DISABILITY THAT HAS BEEN INDICATED.
IF PATIENT DISABLED ON DATE YOU COMPLETE THIS FORM, IS THERE A RETURN TO WORK DATE?
YES
NO
(IF “YES”, GIVE RETURN TO WORK DATE.)
RETURN TO WORK DATE (MM/DD/YYYY)
/ /
IF HOSPITALIZED, GIVE NAME AND ADDRESS OF HOSPITAL AND DATES OF CONFINEMENT.
HOSPITAL NAME
ADMISSION DATE (MM/DD/YYYY)
/ /
DISCHARGE DATE (MM/DD/YYYY)
/ /
PHYSICIAN’S NAME DEGREE SIGNATURE
PHONE NUMBER
FAX NUMBER
DATE (MM/DD/YYYY)
/ /
STAMP
MUST BE FURNISHED UNDER AUTHORITY OF SECTION 6109 OF THE IRS CODE
INDIVIDUAL PRACTITIONER’S S.S. NO. ALL OTHERS - EMPLOYER I.D. NO.
SECTION D ATTENDING PHYSICIAN’S STATEMENT
PATIENT’S FIRST NAME LAST NAME M.I. AGE
ADDRESS
CITY STATE ZIP
NATURE AND ORIGIN OF:
SICKNESS
INJURY
DIAGNOSIS (DESCRIBE COMPLICATIONS, IF ANY)
INDICATE THE DATE AND TYPE OF DIAGNOSTIC TEST USED TO DIAGNOSE CURRENT CONDITION. IF MORE TESTS WERE PERFORMED, PLEASE INCLUDE SUPPORTING DOCUMENTATION.
(MM/DD/YYYY)
/ /
WHEN DID SYMPTOMS FIRST APPEAR OR ACCIDENT HAPPEN?
(MM/DD/YYYY)
/ /
WHEN DID PATIENT FIRST CONSULT YOU FOR THIS CONDITION?
(MM/DD/YYYY)
/ /
IF SICKNESS, WHEN WAS CONDITION FIRST DIAGNOSED?
(MM/DD/YYYY)
/ /
ADDRESS
CITY STATE ZIP
ADDRESS
CITY STATE ZIP
FRAUD NOTIFICATIONS
If you are a resident of or if the policy was issued in one of the following states, we are required to provide you with
the following Fraud Warning Notication:
ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or who knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to restitution, nes, or
connement in prison, or any combination thereof.
ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company les a claim containing
false, incomplete, or misleading information may be prosecuted under state law.
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.
ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to nes and connement in
prison.
CALIFORNIA: For your protection California 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 nes and connement 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, nes, 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.
DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, les a statement of claim
containing any false, incomplete or misleading information is guilty of a felony.
DISTRICT OF COLUMBIA: 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 nes. In addition, an insurer may deny
insurance benets, 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 les a statement of claim or an
application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, les a statement of claim
containing any false, incomplete, or misleading information is guilty of a felony.
INDIANA: A person who knowingly and with the intent to defraud an insurer les a statement of claim containing any false,
incomplete, or misleading information commits a felony.
KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person les 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.
LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to nes and connement in
prison.
MAINE: 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, nes or a denial of insurance benets.
MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benet or who
knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to nes
and connement in prison.
MINNESOTA: A person who les a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, les a statement of
claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud,
as provided in RSA 638:20.
NEW JERSEY: Any person who knowingly les a statement of claim containing any false or misleading information is subject
to criminal and civil penalties.
NEW MEXICO: 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 CIVIL FINES AND CRIMINAL PENALTIES.
WSRCE-1 (0420)
Combined Insurance Company of America
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-800-544-9382 • Fax 312-351-6930
FRAUD NOTIFICATIONS CONTINUED
NEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person les 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 ve thousand dollars and the stated value of the claim for each such violation.
OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or les a claim containing a false or deceptive statement is guilty of insurance fraud.
OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person les 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 benet,
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 ne of not less than ve thousand ($5,000) and not more than ten thousand ($10,000),
or a xed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the
penalty thus established may be increased to a maximum of ve (5) years, if extenuating circumstances are present, it may be
reduced to a minimum of two (2) years.
RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to nes and connement in
prison.
TENNESSEE: 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, nes and denial of insurance benets.
TEXAS: 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 nes and connement in state prison.
VIRGINIA: 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, nes and denial of insurance benets.
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 include imprisonment, nes, and denial of insurance benets.
WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benet or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to nes and connement in
prison.
ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other persons,
les 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, subject to criminal prosecution
and/or civil penalties.
REQUIRED SIGNATURE OF CLAIMANT
By making claim to these proceeds, I declare that all the answers recorded on this statement are true and complete to the
best of my knowledge and belief. I have read the applicable fraud notication statement. I also understand the Company
reserves the right to require or obtain further information, should it be deemed necessary.
X__________________________________________ ______________ _____________________________________
CLAIMANT’S SIGNATURE DATE PLEASE PRINT NAME
I signed on behalf of the claimant, as ___________________________________________ (relationship). If you are the
Power of Attorney, Guardian or Conservator, please attach a copy of the document granting authority.
If your policy/certicate is paid with pre-tax dollars, benets paid may be reported to the IRS. Contact your employer regarding
reporting requirements.
You must sign and date this claim form on the signature line provided on this page. If you do not sign
this claim form, we cannot accept your claim submission.
WSRCE-1 (0420)
CONSENT TO ELECTRONIC TRANSACTIONS, PAYMENTS AND SIGNATURE
1. Consent to Electronic Transactions
By signing and dating this form, you acknowledge, agree and consent to the use by Combined Insurance Company of America
(“Combined”) of electronic transactions, electronic signatures, and to the receipt of the electronic version of certain documents
and records, including but not limited to policy delivery, acknowledgements, notices (including, without limitation, privacy notices),
forms, invoices, explanation of benets, proof of loss, claims documentation, releases, authorizations to obtain medical records,
afdavits, and disclosures, to the extent permitted by law. Electronic documents will be delivered online to your Combined
Self-Service Account. You will be notied via email when delivered. This consent unless withdrawn applies to all transactions
between you and Combined.
You specically acknowledge as part of your consent that certain documents delivered electronically will contain condential
information and information regarding your personal nancial matters (“Personal Financial Information”) and other personally
identiable information; and consent to the delivery of such condential information, Personal Financial Information and
personally identiable information by electronic means. The consent that you grant shall remain in effect until withdrawn by you.
You specically acknowledge as part of your consent that we will replace paper delivery of any particular document with
electronic delivery at our sole discretion as electronic delivery of particular documents becomes available and are consenting
to delivery of documents to you in the following manner: We may send you email transmitting such documents, whether as text
in, attachments to, and/or hyperlinks from such emails. Such emails will be sent to the current email address we have on le for
you. You are responsible for providing us with a valid email address to which you have regular access and you are responsible
for immediately notifying us of any change of email address. Any change to your email address can be completed through our
Self-Service portal at https://my.combinedinsurance.com or by calling the Customer Service Department.
You have the right to receive communications from Combined in paper form. You may withdraw this consent at any time. To
withdraw your consent, you may call our Customer Service Department at 1-800-544-9382, Monday through Friday between
7:30 am and 6:00 pm CST or go to www.combinedinsurance.com/us-en/contact-us to ll out and submit a General Inquiries
form. Your withdrawal will not affect or change in any way the legal effectiveness, validity or enforceability of any documents that
were delivered to you electronically before your withdrawal became effective.
To request a paper copy of any document that was originally provided to you electronically, at no charge, please call our
Customer Service Department.
2. Consent to Electronic Payment
If you submit a payable claim, Combined may offer you the option to receive your benet payment electronically via bank
transfer into a checking account, transfer into a PayPal account, or transfer to a debit card (as available). Combined will not
impose any fees on you for choosing to accept your payment electronically, but your nancial institution may impose a fee or
charge. By signing and dating this form, you are accepting this offer and consenting to accept benet payments electronically.
Consenting to accept payment electronically is voluntary. Your payments received through electronic transfer may be subject to
attachment or garnishment if your account is subject to the same.
If any portion of your claim is payable, you will receive an email with a link to setup an account and provide the routing and
account number for the bank or other account where you wish the funds be deposited. If you do not set up an account and
provide the account information within three (3) calendar days, we will automatically issue the payment via a check mailed to
the address on le.
Unclaimed funds are subject to the applicable laws concerning unclaimed property.
By signing and dating this form, you attest that you are the Principal Insured under the coverage for which your claim was
submitted.
3. Consent to Electronic Signature
You also agree that your electronic signature is the legal equivalent of your manual signature on the above listed documents.
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enforceability of such signature or any such document. You represent that you will be bound by the terms of this consent. This
consent for electronic delivery and signature is effective until withdrawn by you. Doing business electronically will not affect the
validity, legal effect or enforceability of any of your transactions with Combined.
WSRCE-1 (0420) e-Pay
Combined Insurance Company of America
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-800-544-9382 • Fax 312-351-6930
WSRCE-1 (0420) e-Pay
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notices and communications described herein. To ensure delivery of your policy, claim, and/or other documents, the following
minimum hardware and system requirements are necessary to sign, print, retain and receive such documents.
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By signing and dating this form, you are conrming that your computer or electronic device meets the system requirements
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future reference.
Print Name
___________________________________________________
Signature
E-mail Address
___________________________________________________
Date
Combined Insurance Company of America
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-800-544-9382 • Fax 312-351-6930
AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATION
Claim or Policy Number:_________________________________________________________________________________
Name: ______________________________________________ Doctor’s Name: ______________________________
Address: ____________________________________________ Hospital’s Name: _____________________________
Birthdate: _____ /_____ /_____ Adm. ____ /____ /____ Disch. ____ /____ /____
This will authorize COMBINED INSURANCE COMPANY OF AMERICA, PO BOX 6700, Scranton, PA, 18505-0700 to obtain
necessary medical information for the purposes of evaluating my insurance claim. The information to be obtained shall include
information from any Prescription Drug Database, all health care providers, employer, consumer reporting agency, any other
insurance company, or the “MIB” (Medical Information Bureau), which is relevant to my loss or condition being evaluated. I
further authorize Combined to rely on this authorization for two years, or as otherwise permitted by law, to disclose information
about me for purposes of processing my insurance claims, including assistance with return to work.
The information to be disclosed may include but is not limited to:
History of Present Illness Consultant’s Report Discharge Summary
Operative Reports Pathology Reports Laboratory Results
Daily Doctor’s Notes Past Medical History Previous Admissions
X-Ray Reports Blood/Toxicology
The information is needed for the following purpose(s): Evaluation and processing of my insurance claim
I understand that the information released by this authorization may also include information concerning treatment of physical
and mental illness, HIV, alcohol/drug abuse and past medical history.
I understand upon fulllment of the above stated purposes, this consent will expire (24) months following date of signature
without any express revocation. I understand and I have the right to revoke this authorization at any time, and in order to do so,
I must present a written revocation to Combined Insurance Company of America. I understand that revocation will not apply to
my insurance company when the law provides my insurer with the right to contest a claim under my policy/certicate or evaluate
my insurance application for coverage.
Federal and state laws protect the information disclosed pursuant to this authorization. I understand that any disclosure of
information carries with it the potential for re-disclosure and the information may not be protected by the federal condentiality
rules. Treatment, payment, enrollment or eligibility of benets may not be conditioned on obtaining the individual’s authorization.
X ____________________________________________ Date: _______________________________
(Signature of Claimant) (Must be lled in)
X ____________________________________________ _____________________________________
(Signature of Parent or Guardian) (Relationship to Patient if Signed by Guardian)
A photocopy of this authorization may be treated in the same manner as an original.
WSRCE-1 (0420)
Combined Insurance Company of America
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-800-544-9382 • Fax 312-351-6930
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Completed 29 November 2021

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