Transcription of Accident Claim Form - Colonial Life
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Accident Claim Form - Colonial Life
Fax to: Claims From:_____. No#of pages:_____. Or Mail to: Box 100195 Health/Wellness Screening Columbia SC 29202 3195 Claim form Fax this direction. If your name has changed, please attach a copy of legal documentation ( marriage certificate or driver's license). Health/Wellness Screening performed on (First, Last) Birth Date Social Security Number for Claimant _____/_____/_____ Male/Female Relationship to Policy Owner: ___ self ___ spouse ___ dependent ____domestic partner Policy owner (First, Last) Birth Date Social Security Number _____/_____/_____. Mailing Address (Street or PO Box) (Apartment/Unit/Lot Number). (City) (State) (Zip) Daytime Phone Policy owner e-mail address Type of Test Performed - Please complete one Claim form for each claimant & for each calendar year.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding …
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