Fillable Combined Life Insurance Company of New York (Combined Insurance)

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Combined Life Insurance Company of New York (Combined Insurance)

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Country of origin: US
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E-MAIL ADDRESS (Your e-mail address will be updated with this information if different from the e-mail on le) PHONE NUMBER
POLICY NUMBER(S)
ADDRESS
CITY STATE ZIP
FIRST NAME LAST NAME M.I.
Statements made by you on this claim form must be true and complete. You must sign and date this claim form on the
signature line provided on the Fraud Warning page. If you do not sign this claim form, we cannot accept your claim
submission.
After your coverage has been in force for the applicable waiting period as stated in your policy, Combined Life
Insurance Company of New York will pay a Health and Wellness Benet for any one of the health screening tests or
procedures shown below. This benet will only be paid once in a policy year for each person covered. The actual benet
amount you will receive is stated in your Schedule of Benets that accompanies your Policy. To le a claim for a service
provided, you may use our online claim center at www.combinedinsurance.com/claims or fax this completed form to
1-312-351-6930. For Mammography: be sure to include the itemized bill of the procedure from the provider who
performed the screening. Note: In some situations, additional information may be requested.
Please check all screenings performed. Refer to your policy for specic details about qualifying screenings.
m Blood test for triglycerides
m Bone marrow aspiration or biopsy
m Breast ultrasound
m CA 15-3 (blood test for breast cancer)
m CA125 (blood test for ovarian cancer)
m CEA (blood test for colon cancer)
m Chest X-ray
m Colonoscopy
m Fasting blood glucose test
m Flexible sigmoidoscopy
m Hemoccult stool analysis
m Mammography
m Pap smear
m PSA (blood test for prostate cancer)
m Serum cholesterol test
m Stress test on a bicycle or treadmill
m Thermography
The Health and Wellness Benet
NYHWE-1 (0320)
If you had a Health or Wellness Screening at your workplace, please complete below:
PLACE OF
SERVICE
SERVICE
PERFORMED
BY
EMPLOYER
EMPLOYER HUMAN RESOURCE SIGNATURE
m Other
Please enter the date of service. (MM/DD/YYYY)
/ /
Combined Life Insurance Company of New York
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700 • Telephone 1-800-951-6206 • Fax 312-351-6930
NYHWE-1 (0320)
REQUIRED SIGNATURE OF CLAIMANT
FRAUD WARNING
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.
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.
Combined Life Insurance Company of New York
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700 • Telephone 1-800-951-6206 • Fax 312-351-6930
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 Life Insurance Company of
New York (“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 1-800-951-6206, 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.
You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to
otherwise agree, acknowledge, consent, opt-in, or certify to any of the above documents constitutes your signature, acceptance
and agreement as if manually signed by you in writing. You agree that no certication authority or other third-party verication is
necessary to validate such signature, and that the lack of such certication or third party verication will not in any way affect the
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.
NYHWE-1 (0320) e-Pay
Combined Life Insurance Company of New York
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700 • Telephone 1-800-951-6206 • Fax 312-351-6930
NYHWE-1 (0320) e-Pay
You are responsible for ensuring that neither your software nor your Internet service provider inhibits or interferes with the
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.
Operating
Systems
Windows
®
7 or 8.1 or MAC
Browsers
Final release versions of Internet Explorer
®
9.0 or above (Windows only); Firefox 34 or above (Windows
and Mac); Safari™ 5.0 or above (Mac only); Google Chrome 39 or above; Apple iOS 7 or above; Android
4.4 and above
PDF Reader Acrobat Reader
®
or similar software may be required to view and print PDF les
Screen
Resolution
800 x 600 minimum
Enabled
Security
Settings
Allow per session cookies
By signing and dating this form, you are conrming that your computer or electronic device meets the system requirements
necessary to print, store and receive claims documents electronically and that you may be able to access such documents for
future reference.
Print Name
___________________________________________________
Signature
E-mail Address
___________________________________________________
Date
Combined Life Insurance Company of New York
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700 • Telephone 1-800-951-6206 • Fax 312-351-6930
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Combined Life Insurance Company of New York (Combined Insurance)

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Completed 20 April 2022

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