Transcription of Accident Claim Form - colonialnj.com
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Accident Claim Form - colonialnj.com
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 or attempting to defraud the company.
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