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. You must attached a copy of the bill(s) for each test submitted. Please review your policy(ies) for the list of covered tests prior to completing this form . The Health/Wellness Screening benefit is NOT payable for routine physical examinations.

: 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

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