Form S-2029-Fl - Sickness Claim Form

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SICKNESS CLAIM FORM

Failure to complete this form in its entirety may result in a delay in processing this claim.

FILING CLAIM FOR (check all that apply):

Sickness

Pregnancy

Hospitalization

Deceased - Date Deceased

:___/___/___

Short-Term Disability/

Hospital Intensive

Cancer

Hospital Indemnity

CareAssist

Life

Specified Health Event

Sickness Disability Rider

Care

Policy Number

INSTRUCTIONS:

Complete Section A: Policyholder/Patient Information and sign your claim form.

Have the treating physician complete Section B: Physician's Statement and sign the claim form.

If you are filing for disability, please complete the Initial Disability Claim Form (S00224) as well. Forms are available on our web site at .

Submit all bills related to this claim, such as hospital, surgery, etc. All bills should include the diagnosis, services rendered, and actual charges for the

service.

If hospitalized and/or confined to an intensive care unit, please send a copy of your hospital bill showing charges and the number of days you were

confined.

The items above can be obtained directly from your healthcare provider(s) by requesting a UB04 (hospital bill) or HCFA1500 (non-hospital bill).

Be sure to include your policy number(s) on all documents.

Policyholder Information

(Please print.)

Initial

First Name

Last Name

Mailing Address

City