Fillable Continuation of Disability Claim Form (Combined Insurance)

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Continuation of Disability Claim Form (Combined Insurance)

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The Continuation of Disability Claim Form (Combined Insurance) form is 6 pages long and contains:

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  • 29 check-boxes
  • 243 other fields

Country of origin: US
File type: PDF

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E-MAIL ADDRESS
PLEASE DESCRIBE ANY COMPLICATIONS OF INJURY OR ILLNESS SINCE LAST REPORT.
MAILING ADDRESS
CITY STATE ZIP
CLAIM NUMBER
POLICY/CERTIFICATE NUMBER(S)
PRIMARY PHONE
LIST MEDICAL TREATMENTS RECEIVED SINCE LAST REPORT
DOCTOR’S NAME TREATMENT FROM (MM/DD/YYYY)
DATES:
/ /
THROUGH (MM/DD/YYYY)
/ /
DOCTOR’S NAME TREATMENT FROM (MM/DD/YYYY)
DATES:
/ /
THROUGH (MM/DD/YYYY)
/ /
ADDRESS
ADDRESS
FIRST NAME LAST NAME M.I.
CLAIMANT STATEMENT - PLEASE COMPLETE AND RETURN
CITY STATE ZIP
CITY STATE ZIP
HOSPITAL CONFINEMENT SINCE LAST REPORT
HOSPITAL NAME
HOSPITAL NAME
ADDRESS
ADDRESS
CITY STATE ZIP ADMISSION DATE (MM/DD/YYYY)
/ /
DISCHARGE DATE (MM/DD/YYYY)
/ /
CITY STATE ZIP ADMISSION DATE (MM/DD/YYYY)
/ /
DISCHARGE DATE (MM/DD/YYYY)
/ /
HAVE YOU RETURNED TO WORK OR YOUR USUAL DAILY ACTIVITIES?
YES
NO
IF YES, PLEASE INDICATE THE ACTUAL DATE YOU RETURNED TO WORK OR YOUR USUAL DAILY ACTIVITIES.
DATE (MM/DD/YYYY)
/ /
IF YOU RETURNED TO WORK, PLEASE INDICATE ONE OF THE FOLLOWING: FULL TIME NO RESTRICTIONS
FULL TIME WITH RESTRICTIONS
PART TIME
IF YOU RETURNED TO WORK WITH RESTRICTIONS OR PART TIME, PLEASE INDICATE WORK RESTRICTIONS ON YOUR RETURN TO WORK DATE.
PLEASE INDICATE THE DATE THESE WORK RESTRICTIONS WILL BE APPLICABLE THROUGH. (MM/DD/YYYY)
/ /
WORKERS’ COMPENSATION
ACT YES
NO
SOCIAL SECURITY
ACT YES
NO
STATE
DISABILITY YES
NO
IF YES, TO ANY OF THE ABOVE, PLEASE
SUBMIT A COPY OF THE AWARD OR
DENIAL LETTER IF RECEIVED UNLESS
ALREADY PROVIDED.
HAVE YOU FILED FOR A CLAIM UNDER ANY OF THE FOLLOWING BENEFITS LISTED BELOW?
DATE (MM/DD/YYYY)
/ /
SIGNATURE
WNCDE-1 (0420)
Combined Life Insurance Company of New York
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-888-441-7936 • Fax 312-351-6930
Continuation of Disability Claim Form
WNCDE-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.
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
EMPLOYEE’S FIRST NAME LAST NAME M.I.
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)
WNCDE-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
WNCDE-1 (0420)
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
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-888-441-7936 • 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 1-888-441-7936, 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.
WNCDE-1 (0420) e-Pay
Combined Life Insurance Company of New York
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-888-441-7936 • Fax 312-351-6930
WNCDE-1 (0420) 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
Worksite Solutions Division
Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700
Telephone 1-888-441-7936 • Fax 312-351-6930
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Continuation of Disability Claim Form (Combined Insurance)

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Completed 30 November 2021

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