Form 10304 - Disability Insurance Claim printable pdf download

disability insurance claim form

P.O. Box 100102 • Columbia, South Carolina 29202-3102

803-735-1251 Ext. 45922 • 800-753-0404

803-754-1153 (Claims Fax) •

fraud WarninG: Any person who knowingly, and with intent to injure, defraud or deceive any insurance company, files a statement of claim containing

any false, incomplete or misleading information is guilty of a felony.

To prevent delays, complete claim in its entirety. Incomplete claims will be returned.

Part i – insured information

1. insured’s name

2. ID Number

3. Date of Birth

First

Middle

Last

Mo.

Day

Yr.

4. Insured’s Address

Street

City

State

ZIP

5. Insured’s Sex

h Male

h Female

6. Job Description and Duties

7. If disability is due to an accident, did injury occur at work? h Yes h No, If yes, have you filed a Workers Compensation claim? h Yes h No

8. I AuThOrIZE ANY PhYSICIAN, MEDICAL PrACTITIONEr, hOSPITAL, CLINIC, Drug AND ALCOhOL TrEATMENT FACILITY, OThEr hEALTh FACILITY,

CONSuMEr rEPOrTINg AgENCY, ThE MEDICAL INFOrMATION BurEAu, SOCIAL SECurITY ADMINISTrATION, INSurANCE Or rEINSurANCE COM-

PANY, Or EMPLOYEr TO rELEASE ANY AND ALL MEDICAL AND NON-MEDICAL INFOrMATION ABOuT ME IN ITS POSSESSION TO COMPANION LIFE

INSurANCE COMPANY Or ITS LEgAL rEPrESENTATIvES. MEDICAL INFOrMATION MEANS ALL INFOrMATION IN ThE POSSESSION OF Or DErIvED

FrOM PrOvIDErS OF hEALTh CArE rEgArDINg MY MEDICAL hISTOrY, MENTAL Or PhYSICAL CONDITION, Or TrEATMENT. I uNDErSTAND ThAT

COMPANION LIFE WILL NOT rELEASE ANY INFOrMATION OBTAINED TO ANY PErSON Or OrgANIZATION ExCEPT TO rEINSurANCE COMPANIES,

ThE MEDICAL INFOrMATION BurEAu, Or OThEr PErSONS Or OrgANIZATIONS PErFOrMINg BuSINESS Or LEgAL SErvICES IN CONNECTION

WITh MY APPLICATION, CLAIM, Or AS MAY BE LAWFuLLY PErMITTED, Or AS I MAY FurThEr AuThOrIZE. I kNOW ThAT I MAY rEquEST AND

rECEIvE A COPY OF ThIS AuThOrIZATION. I AgrEE ThAT A PhOTOCOPY OF ThIS AuThOrIZATION ShALL BE AS vALID AS ThE OrIgINAL. I AgrEE

ThAT ThIS AuThOrIZATION ShALL BE vALID FOr ThE DurATION OF MY CLAIM.

SIgNATurE OF EMPLOYEE

PhONE NO. (

)

DATE

Part ii – Physician information

9. Date first treated for this disability

11. If hospitalized, date admitted

0. Dates certified disabled and unable to work

Mo.

Day

Yr.

From:

Mo.

Day

Yr.

Thru

Mo.

Day

Yr.

Mo.

Day

Yr.

12. Nature of Disability

h Accident

h Sickness

h Maternity

(If Accident or Maternity, please complete reverse side of this form.)

13. Diagnosis

14. Diagnosis Code

15. Prognosis

16. Physical findings (list all test results, or enclose test)

Test

Date

results

Test

Date

results

Blood Pressure (Systolic)

(Diastolic)

(Date)

remarks:

treatment

Date of onset of this condition?

List all dates of treatment for this condition since patient ceased work

Date of next office visit

has patient been referred to any other physician

Yes

No Date(s)

If “Yes,” name and address

Specialty

Nature of treatment for this condition (including surgery/medications)

Was patient hospitalized for this condition?

Yes

No If “Yes,” date(s) admitted_______________ date(s) discharged

Name and address of hospital(s)

Was surgery performed?

Yes

No If “Yes,” Date

Procedure

CPT Code

Progress (please check one)

recovered

Improved

unchanged

retrogressed

17. imPairment

What are the patient’s current physical limitations and restrictions?

No limitation of functional capacity; capable of heavy work, no restrictions. (Lifting 100 lbs. maximum with frequent lifting and/or carrying objects

weighing up to 50 lbs.)

Medium manual activity. (Lifting 50 lbs. maximum with frequent lifting and/or carrying of objects weighing up to 25 lbs.)

Slight limitation of functional capacity; capable of light work. (Lifting 20 lbs. maximum with frequent lifting and/or carrying of objects weighing up to

10 lbs. Even though the weight lifted may be only a negligible amount, a job is in this category when it involves sitting most of the time with a degree

of pushing and pulling of arm and/or leg controls, or when it requires walking or standing to a significant degree.)

Moderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity. (Lifting 10 lbs. maximum and occasionally lifting

and/or carrying articles. Although a sedentary job is defined as one which involves sitting, a certain amount of walking and standing is often necessary

in carrying out job duties.)

Severe limitation of functional capacity; incapable of minimal (sedentary) activity.

What is the psychiatric impairment (if applicable)?

Inadequate information to make assessment.

Essentially good functioning in all areas. Occupationally and socially effective.

Slight difficulty in occupational functioning, but generally functioning well. has some meaningful interpersonal relationships.

Moderate impairment in occupational functioning. Limited in performing some occupational duties.

Major impairment in several areas – work, family relations. Avoidant behavior, neglects family, is unable to work.

Inability to function in almost all areas.

10304

rev. 7/10

SEE rEvErSE SIDE OF FOrM