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).
: 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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