Chubb11-62-1116-AUS Combined Insurance Claim Form

1. You should complete Section 1 in full. If you do not fully complete the Claim Form this may result in delays processing your claim while we seek missing information. Please see the Important Notes for Particular Benefits. 2. Your Medical Practitioner, and only your Medical Practitioner should complete Section 2 in full.

  Section, Insurance, Combined insurance, Combined

Claims Made Easy - Combined Insurance

Statement found in SECTION C on the third page. 5. Have your physician complete SECTION D, the Attending Physician’s Statement, on the fourth page. 6. Review the Fraud Notification for your state on the fifth page. 7. Sign and date the claim form on the signature line provided at the end of the Fraud Notification page of the claim form.

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Combined Life Insurance Company of New York

If you had a Health or Wellness Screening at your workplace, please complete below: PLACE OF SERVICE SERVICE PERFORMED BY EMPLOYER EMPLOYER HUMAN RESOURCE SIGNATURE m Other Please enter the date of service. (MM/DD/YYYY) / / Combined Life Insurance Company of New York

  Workplace

Claims Made Easy - Combined Insurance

3. IF MEDICAL OR HOSPITAL BENEFITS ARE CLAIMED, ITEMIZED BILLS MUST BE ATTACHED. SECTION A CLAIMANT STATEMENT PLEASE PRINT Statements made by you on this claim form must be true and complete. Please review the Fraud Warning for your state on the attached Fraud Notification pages.

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This form must be fully completed and returned within 90 ...

Insurance, any healthcare provider, any insurance or reinsurance company, administrators of government benefits or other benefits programs, or any person having knowledge of me ... Nature of Treatment (e.g. date and type of surgery, including medication)_____ ... Personal Financial Information and personally identifiable information by ...

  Treatment, Financial, Reinsurance

Beneficiary Statement for Life Insurance

Combined Insurance Company of America. Claim Department • PO Box 6700 • Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930. Beneficiary Statement for Life Insurance Claim Number: TO BE COMPLETED BY BENEFICIARY . DECEDENT INFORMATION. Deceased’s Full Name

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Supplemental Disability Claim Form - Combined Insurance

Combined Insurance Company of America Claim Department • P.O. Box 6700 • Scranton, PA 18505-0700 • Telephone 1-800-225-4500 • Fax 312-351-6930

  Form, Insurance, Combined insurance, Combined

Claims Made Easy - Combined Insurance

FILING A CLAIM BY MAIL 1.wnload the claim form. Do 2. Print all pages of the claim form. 3. Complete all sections of the Claimant Statement. 4.

  Insurance, Combined insurance, Combined

COMPAGNIE D’ASSURANCE COMBINED D’AMÉRIQUE …

Page 2 de 5 DÉCLARATION DU MÉDECIN TRAITANT Il incombe au patient de faire remplir ce formulaire et de payer les frais s’y rattachant. Nom du patient : Date de naissance : (MM/JJ/AAAA) 1.

Your Pet Insurance Policy Wording. Please keep this safe

your policy. The insurance contract This Policy is a legal contract between you and us. The Policy and Schedule make one document and must be read together. Please keep them together. The contract is based on the information you …

  Policy, Your, Insurance, Insurance policy, Your policy

Your car insurance policy booklet

Your certificate of motor insurance will show if your policy includes business use and the type of business use you have. Commuting is driving to and from a permanent . place of work, for either part of the journey, or for . the whole journey. This includes driving to and from a car park, railway station or bus stop as

  Policy, Your, Insurance, Insurance policy, Your policy