Colonial Life - Health / Wellness Screening Claim Form (Page 3 of 4) in pdf

Colonial Life - Health / Wellness Screening Claim Form Page 3

CERTIFICATION

Policy owner’s Name__________________________________ Social Security #____________________

I have checked the answers on this claim form and they are correct. I certify under penalty of perjury that my

correct social security number is shown on this form. I acknowledge that I received the Claim Fraud Statements

on page 2 of this form and that I read the statement required by the State Department of Insurance for my state,

if my state was listed on the form. Fraud Warning: Any person who knowingly and with intent to

defraud any insurance company or other person files a statement of claim containing any

materially false information or conceals, for the purpose of misleading, information

concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Please remember to also sign and date the attached authorization required to process your

claim.

X_________________________

X __________________

Claimant’s Signature

Policy owner’s Signature

Date (MM/DDD/YYYY)

Fax this direction.

70067%12

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Colonial Life insurance products are underwritten by Colonial Life & Accident Insurance Company, for which Colonial Life is the marketing brand.

Colonial Life - Health / Wellness Screening Claim Form Page 3