SHORT TERM DISABILITY CLAIM FORM

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 AC

Several states require that the following statement appear on the claim forms: For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of loss is guilty of a crime and may be subject to fines and confinement in state prison.

Loading..

Tags:

  Form, Terms, Short, Claim, Disability, Short term disability claim form

Information

Related search queries