Transcription of Accident Claim Form - Making Benefts Count
{{id}} {{{paragraph}}}
Example: biology
Accident Claim Form - Making Benefts Count
From:_____ Fax to: Claims No#of pages:_____ Phone Number: Or Mail to: Box 100195 Universal Claim form Columbia SC 29202-3266. Please be sure to send the following Information: Medical Documentation for your condition Diagnosis (ICD9) codes, Signed and dated authorization Fax this direction. OPTIONAL SERVICE RELEASE AGREEMENT Please initial below for optional services. Any other marks used (check mark, x, etc.) will not be considered as authorization and will be processed as blank. I authorize Colonial Life to facilitate processing this Claim by releasing its details to the individual inquiring on my behalf.
Colonial Life products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand. 08727‐47 02/11‐Visit us online at Coloniallife.com
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: