Transcription of CONTINENTAL AMERICAN INSURANCE COMPANY …
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CONTINENTAL AMERICAN INSURANCE COMPANY …
CONTINENTAL AMERICAN INSURANCE COMPANY claim FORM Post Office Box 427 Columbia, South Carolina 29202 Phone (800) 433-3036 Fax (866) 849-2970 Pl ease Read Instructions Before Completing PART A CERTIFICATEHOLDER/CLAIMANT S STATEMENT 1 CERTIFICATEHOLDER S NAME CERTIFICATE NO. SOCIAL SECURITY NO. DATE OF BIRTH SEX 2 CERTIFICATEHOLDER S ADDRESS STREET CITY STATE ZIP CODE 3 CLAIMANT S NAME (PERSON WHO IS SICK OR INJURED) DATE OF BIRTH RELATIONSHIP TO CERTIFICATEHOLDER CERTIFICATEHOLDER S TELEPHONE # (WITH AREA CODE) 4 CERTIFICATEHOLDER S OCCUPATION DESCRIBE WHEN AND HOW YOUR ACCIDENT OCCURRED OR THE ONSET AND NATURE OF YOUR ILLNESS.
CONTINENTAL AMERICAN INSURANCE COMPANY CLAIM FORM Post Office Box 427 Columbia, South Carolina 29202 Phone (800) 433-3036 PART B …
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