Printable Claim Forms From Combined Insurance COMBINED INSURANCE COMPANY OF AMERICA COMPAGNIE D ASSURANCE COMBINED D AM RIQUE CANADIAN HEAD OFFICE P O BOX 3720 MIP MARKHAM ON L3R 0X5 TELEPHONE 1 888 234 4466 wwwbined ca This form must be fully completed and returned within 90 days of the loss CLAIMANT S STATEMENT PLEASE PRINT IMPORTANT Review your claim form Is it
Follow the Claimant Instructions below to complete the form Upon completion of the first page you can Mail OR fax the document to the company along with any supporting documentation If you are filing for a disability or hospital benefit Sections C D must be completed What is needed to file a claim A Claims require basic information like your name address telephone number policy number and a brief description of your loss Additional documents vary according to policy coverage and the extent of your loss If we need more information we ll request it in writing or by telephone Q
Printable Claim Forms From Combined Insurance
Printable Claim Forms From Combined Insurance
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Download the claim form You can complete the claimant information first page online however you cannot submit the information electronically Follow First Page instructions below and upon completion of the first page print the document which will be 2 pages Sign and date the first page including the Authorization to Release Information If you are filing for the medical expense benefit only under your accident policy a claim form may not be needed print the document which will be 6 pages Combined Insurance Company of America Claim Department PO Box 6700 Scranton PA 18505 0700 Telephone 1 800 225 4500 Fax 312 351 6930
6 Please send this Claim Form together with all supporting documents within 30 days of the commencement of your disability via post to Combined Insurance Private Bag COMBINED Remuera Auckland 1541 via fax to 09 520 9009 or email the form to claims combined If you do not report your claim within 30 days and we consider the delay has Download the claim form Print all pages of the claim form Complete all sections of the Claimant Statement If you are claiming disability have your employer complete and sign the Employer s Statement found in SECTION C on the third page Have your physician complete SECTION D the Attending Physician s Statement on the fourth page
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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 To le a claim for a service provided please submit this completed form along with documentation of the health screening test or procedure from the provider who performed Combined Insurance Worksite Solutions Claim Department PO Box 6700 Scranton PA 18505 0700 Fax 1 312 351 6930 Phone 1 800 544 9382
01 Edit your combined insurance claim form online Type text add images blackout confidential details add comments highlights and more 02 Sign it in a few clicks Draw your signature type it upload its image or use your mobile device as a signature pad 03 Share your form with others Send combined life insurance via email link or fax Submits an application or files a claim containing a false or deceptive statement may have violated state law FOR RESIDENTS OF ALL OTHER STATES Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an enrollment form for insurance is guilty of a crime and may be
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COMBINED INSURANCE COMPANY OF AMERICA COMPAGNIE D ASSURANCE COMBINED D AM RIQUE CANADIAN HEAD OFFICE P O BOX 3720 MIP MARKHAM ON L3R 0X5 TELEPHONE 1 888 234 4466 wwwbined ca This form must be fully completed and returned within 90 days of the loss CLAIMANT S STATEMENT PLEASE PRINT IMPORTANT Review your claim form Is it
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Follow the Claimant Instructions below to complete the form Upon completion of the first page you can Mail OR fax the document to the company along with any supporting documentation If you are filing for a disability or hospital benefit Sections C D must be completed
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