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Claims Made EasyYour claim is processed ten days faster* when you submit a claim onlineat www.CombinedInsurance.com/ClaimsFILING A CLAIM BY MAIL1.Download the claim form.2. Print all pages of the claim form.3. Complete all sections of the Claimant Statement.4. If you are claiming disability, have your employer complete and sign the Employer’sStatement found in SECTION C on the third page.5. Have your physician complete SECTION D, the Attending Physician’s Statement, onthe fourth page.6. Review the Fraud Notification for your state on the fifth or sixth page.7. Sign and date the claim form on the signature line provided at the end of the FraudNotification page of the claim form. If you do not sign the Fraud Notification page, wecannot accept your claim submission.8. Elect to receive documents electronically and, if your claim is payable, opt in toreceive your benefit payment sent electronically via bank transfer into a checkingaccount, transfer into a PayPal account, or transfer to a debit card (as available).To authorize this, please complete and sign the Consent to Electronic Transactions,Payments and Signature document.9. Sign and date the Authorization to Obtain and Disclose Health Information.10. Send your signed, completed claim form with the Attending Physician’s Statement,Employer Statement, if applicable, and any medical bills or documentation that youmay have related to your accident or illness to:Combined Insurance Claim DepartmentPO Box 6700Scranton, PA 18505-0700* On averageCombined Insurance Company of America Chicago, ILCIRCE-1 (0320)
Claims Made EasyHELPFUL TIPS:First page (Claimant completes)Please include your complete name and current mailing address on the claim form as any paymentand/or correspondence will be sent to the address indicated on the claim form. Indicate your policynumbers/certificate numbers on the claim form; this will help us respond quicker.Accident: For loss due to an accidental bodily injury, please complete the Accident section ofthe form including a detailed description of how the accident occurred.Sickness: If filing for loss due to sickness, fill in the section of the form relating to symptomsand diagnosis. You may be requested to provide additional details regarding medicaltreatment you received within the 5 years prior to your policy effective date.Critical Illness: If filing a critical illness claim, please fill in the date of diagnosis and provide acopy of the pathology report or test results confirming the diagnosis and the level of severity.Hospitalization: If hospitalized, provide us with the name and address of the hospital includingthe admission and discharge dates. Please also send a copy of the itemized hospital billincluding the number of days you were an inpatient.Disability: If you were disabled and have disability coverage, give the exact dates of the totaland/or partial disability. If you are still disabled at the time you submit your claim form, anotherclaim form will be sent to you for continuing disability.Wellness: If filing for wellness/preventative/health screening benefits, please review yourpolicy carefully to ensure the test or procedure is covered under your policy. Do not use theattached claim form if filing for wellness or health screening benefits. Rather use the Healthand Wellness claim form which can be found at www.combinedinsurance.com/forms.Additional: Please be sure to sign and date the Authorization to Release Information. This willprevent unnecessary delays in the event additional information is needed.Third page (Employer completes)If you are employed outside the home, your employer must verify your disability by completingSection C – Employer’s Statement. Please note: If the insured is a student, the school principal shouldcomplete this section.Fourth page (Doctor completes)Your primary physician must complete Section D – Attending Physician’s Statement in its entirety.Failure to make sure that your physician fills in all necessary information on the claim form may causedelays in the processing of your claim.For your records, we suggest that you keep a copy of the completed claim form and any bills yousubmit. Note the date mailed. Mail all pages of the completed form and any enclosures to:Combined Insurance Claim DepartmentP O Box 6700, Scranton, PA 18505-0700Remember, your claim is processed ten days faster* when you submit a claim online atwww.CombinedInsurance.com/Claims* On averageCombined Insurance Company of America Chicago, ILCIRCE-1 (0320)
Combined Insurance Company of AmericaClaim Department P.O. Box 6700 Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-69301.2.3.IMPORTANT INSTRUCTIONS FOR FILING CLAIMUSE THIS CLAIM FORM FOR ALL CLAIMS EXCEPT FOR WELLNESS/PREVENTATIVE/HEALTH SCREENING BENEFITS.IF DISABILITY IS CLAIMED, PLEASE HAVE YOUR EMPLOYER OR SCHOOL COMPLETE SECTION C, THE EMPLOYER’S STATEMENT.IF MEDICAL OR HOSPITAL BENEFITS ARE CLAIMED, ITEMIZED BILLS MUST BE ATTACHED.CLAIMANT STATEMENTSECTION APLEASE PRINTFIRST NAMELAST NAMEM.I.E-MAIL ADDRESS (Your e-mail address will be updated with this information if different from the e-mail on file)PLEASE LIST OTHER NAMES THAT YOU MAY USE SUCH AS MAIDEN NAME, NICKNAME, ETC. PRIMARY PHONESECONDARY PHONEMAILING ADDRESSCITYSTATESOCIAL SECURITY # (LAST 4 DIGITS)BIRTH DATE (MM/DD/YYYY)/HEIGHT (FT/IN)ZIPWEIGHT (LBS)MALEFEMALE/POLICY/CERTIFICATE NUMBER(S)EMPLOYER’S NAMEEMPLOYER’S ADDRESSCITYSTATEEMPLOYER’S CONTACT NAMEEMPLOYER’S CONTACT PHONE NUMBERZIPEMPLOYER’S CONTACT FAX NUMBERYOUR OCCUPATIONMONTHLY EARNINGS ,BRIEFLY DESCRIBE YOUR OCCUPATIONAL DUTIESHAVE YOU FILED A CLAIM UNDER THE FOLLOWING:WORKERS’ COMPENSATIONACT?YESSOCIAL SECURITYACT?YESNONOSTATE DISABILITYBENEFITS?YESNOIF YES TO ANY OF THE PRECEDING,PLEASE SUBMIT A COPY OF THE AWARDOR DENIAL LETTER IF RECEIVED.IF YOU HAVE OTHER ACCIDENT-SICKNESS DISABILITY INSURANCE, GIVE COMPANY NAME, ADDRESS, AND BENEFIT AMOUNT. (IF NONE, STATE “NONE”)COMPANY NAMEADDRESSCITYSTATEBENEFIT AMOUNTWEEKLY ,BI-WEEKLY ,MONTHLY ZIP,Statements made by you on this claim form must be true and complete. Please review the Fraud Warning for your stateon the attached Fraud Notification pages. You must sign and date this claim form on the signature line provided on theFraud Notifications page. If you do not sign this Fraud Notifications page, we cannot accept your claim submission.CIRCE-1 (0320)
SECTION BCLAIMANT STATEMENTPLEASE COMPLETE ALL APPLICABLE SECTIONS BELOW AND SUBMIT DOCUMENTATION TO SUBSTANTIATE COVERED SERVICES CLAIMED UNDER YOUR POLICY.COMPLETE FORACCIDENT CLAIMDATE OF ACCIDENT (MM/DD/YYYY)/INJURIES SUSTAINED/PLEASE PROVIDE AN EXACT DESCRIPTION OF WHERE YOU WERE WHEN ACCIDENT OCCURRED INCLUDING A DETAILED DESCRIPTION OF WHAT HAPPENED TO YOU.COMPLETE FORSICKNESS CLAIMIF FILING FOR CRITICAL ILLNESS BENEFITS, PLEASE ATTACH A COPY OF THE PATHOLOGY REPORT OR TEST(S) THAT CONFIRM THE DIAGNOSIS AND THE SEVERITY OF THE CONDITION.DATE OF DIAGNOSIS FOR CURRENT SICKNESS SICKNESS DIAGNOSIS IF KNOWN(MM/DD/YYYY)//PLEASE PROVIDE ADDITIONAL DETAILS INCLUDING SYMPTOMS.COMPLETE FOR EITHERACCIDENT OR SICKNESS CLAIMFIRST ATTENDING PHYSICIAN’S NAMEADDRESSCITYSTATEPHONE NUMBERFAX NUMBERZIPINITIAL DATE OF TREATMENT (MM/DD/YYYY) LAST DATE OF TREATMENT (MM/DD/YYYY)////SECOND ATTENDING PHYSICIAN’S NAMEADDRESSCITYSTATEPHONE NUMBERFAX NUMBERZIPINITIAL DATE OF TREATMENT (MM/DD/YYYY) LAST DATE OF TREATMENT (MM/DD/YYYY)////HOSPITAL NAMEHOSPITAL ADDRESSCITYSTATEPHONE NUMBERFAX NUMBERADMISSION DATE (MM/DD/YYYY)/COMPLETE FORBETWEEN WHAT DATES WERE YOU UNABLE TO PERFORM ANY DUTIES?FROM (MM/DD/YYYY)/DATE LAST WORKED (MM/DD/YYYY)/DISCHARGE DATE (MM/DD/YYYY)//DISABILITY CLAIMTOTAL DISABILITY://ZIP/THROUGH (MM/DD/YYYY)//PARTIAL DISABILITY:BETWEEN WHAT DATES WERE YOU ABLE TO PERFORM ONLY PARTIAL DUTIES?FROM (MM/DD/YYYY)//THROUGH (MM/DD/YYYY)//DATE RETURNED TO WORK (MM/DD/YYYY)//PLEASE HAVE YOUR EMPLOYER COMPLETE AND SIGN SECTION C - EMPLOYER’S STATEMENT FOUND ON THE NEXT PAGE. IF THE INSURED IS A STUDENT, THESCHOOL PRINCIPAL SHOULD COMPLETE THIS SECTION.CIRCE-1 (0320)
EMPLOYER’S STATEMENTSECTION CIF YOU ARE EMPLOYED OUTSIDE THE HOME, YOUR EMPLOYER MUST VERIFY YOUR DISABILITY BY COMPLETING SECTION C – EMPLOYER’S STATEMENT. PLEASE NOTE: IF THE INSUREDIS A STUDENT, THE SCHOOL PRINCIPAL SHOULD COMPLETE THIS SECTION.EMPLOYEE’S FIRST NAMELAST NAMEM.I.CITYSTATEPHONE NUMBERBIRTH DATE (MM/DD/YYYY)/DATE LAST WORKED (MM/DD/YYYY)/ZIPCLAIM NUMBER (IF AVAILABLE)/DATE RETURNED TO WORK (MM/DD/YYYY)///MONTHLY EARNINGSFULL TIME, PART TIMEPOLICY NUMBER(S)EMPLOYEE’S OCCUPATIONDESCRIPTION OF OCCUPATION’S PRIMARY DUTIESWORKERS’ COMPENSATION CLAIM FILED FOR THIS DISABILITY?YESNOPAID?YESNOIF YES PROVIDE THE NAME, ADDRESS AND TELEPHONE NUMBER OF COMPENSATION CARRIER. ALSO, SEND REPORT OF INITIAL INJURY.NAMEADDRESSCITYSTATEZIPPHONE NUMBERPHYSICAL JOB DEMANDS (HH hours, MM minutes)SITTINGHLIFTING:HMMPER DAYLESS THAN 15LBSWALKINGHHM15 TO 45LBSMPER DAYCLIMBING STAIRS/LADDERSMORE THAN 45LBSHHMSTOOPING/BENDING:MPER DAYDRIVINGNONEHHMSELDOMMPER DAYFREQUENTTOTAL DISABILITY:BETWEEN WHAT DATES DID THE EMPLOYEE NOT PERFORM ANY JOB DUTIES?PARTIAL DISABILITY:BETWEEN WHAT DATES DID THE EMPLOYEE ONLY PERFORM PARTIAL JOB DUTIES?FROM (MM/DD/YYYY)FROM (MM/DD/YYYY)//THROUGH (MM/DD/YYYY)///DURING PARTIAL DISABILITY, DID/WILL EMPLOYEE RECEIVE 75% OR MORE OF HIS PRE-DISABILITY INCOME?THROUGH (MM/DD/YYYY)/YES/NO/IF NO, WHAT PERCENTAGE? %DESCRIPTION OF DUTIES PERFORMED (IF ON PARTIAL DISABILITY)EMPLOYER CONTACT NAMECONTACT’S POSITIONDATE (MM/DD/YYYY)/SIGNATURECIRCE-1 (0320)PHONE NUMBERFAX NUMBER/
SECTION DATTENDING PHYSICIAN’S STATEMENTPATIENT’S FIRST NAMELAST NAMEM.I.AGEADDRESSCITYSTATEZIPDIAGNOSIS (DESCRIBE COMPLICATIONS, IF ANY)NATURE AND ORIGIN OF: SICKNESSINJURYWHEN DID SYMPTOMS FIRST APPEAR OR ACCIDENT HAPPEN? WHEN DID PATIENT FIRST CONSULT YOU FOR THIS CONDITION? IF SICKNESS, WHEN WAS CONDITION FIRST //INDICATE THE DATE AND TYPE OF DIAGNOSTIC TEST USED TO DIAGNOSE CURRENT CONDITION. IF MORE TESTS WERE PERFORMED, PLEASE INCLUDE SUPPORTING DOCUMENTATION.(MM/DD/YYYY)//HAS PATIENT EVER HAD SAMEOR SIMILAR CONDITION?(IF “YES”, STATE WHEN AND DESCRIBE.) (MM/DD/YYYY)YES/NO/HOW DID CONDITION ORIGINATE?DESCRIBE ANY OTHER DISEASE OR INFIRMITY AFFECTING PRESENT CONDITION.NATURE OF SURGICAL OR OBSTETRICAL PROCEDURE(S), IF ANY. (DESCRIBE FULLY)PROCEDUREDATE (MM/DD/YYYY)//OPEN OR CLOSED REDUCTIONOPENNAME OFFACILITYCLOSEDGIVE DATES OF TREATMENT AND NATURE OF TREATMENT OTHER THAN SURGICAL.OFFICEDATE (MM/DD/YYYY)NATURE OFTREATMENT(S) EMERGENCYROOM (ER)URGENTCAREFACILITY//////NAME OFFACILITYDATE (MM/DD/YYYY)/NATURE OFTREATMENT/NAME OFFACILITYDATE (MM/DD/YYYY)/NATURE OFTREATMENT/NAME OFFACILITYIS THE PATIENT STILL HOW LONG WAS OR WILL PATIENT BE CONTINUOUSLY TOTALLY DISABLEDUNDER YOUR CARE? (UNABLE TO WORK)?THROUGH (MM/DD/YYYY)FROM (MM/DD/YYYY)YESNO/HOW LONG WAS OR WILL PATIENT BE PARTIALLY DISABLED?(ONLY ABLE TO WORK PART TIME OR PERFORM PARTIAL JOB DUTIES)?//FROM (MM/DD/YYYY)//THROUGH (MM/DD/YYYY)///PLEASE STATE RESTRICTIONS PLACED ON PATIENT FOR ANY DISABILITY THAT HAS BEEN INDICATED.IF PATIENT DISABLED ON DATE YOU COMPLETE THIS FORM, IS THERE A RETURN TO WORK DATE?YESNORETURN TO WORK DATE (MM/DD/YYYY)/(IF “YES”, GIVE RETURN TO WORK DATE.)IF HOSPITALIZED, GIVE NAME AND ADDRESS OF HOSPITAL AND DATES OF CONFINEMENT.HOSPITAL NAME/ADMISSION DATE (MM/DD/YYYY)/DISCHARGE DATE (MM/DD/YYYY)//ADDRESSCITYSTATEPHYSICIAN’S NAMEPHONE NUMBERDEGREEFAX NUMBERZIPSIGNATUREDATE (MM/DD/YYYY)/STAMP/ADDRESSCITYINDIVIDUAL PRACTITIONER’S S.S. NO.CIRCE-1 (0320)STATEMUST BE FURNISHED UNDER AUTHORITY OF SECTION 6109 OF THE IRS CODEALL OTHERS - EMPLOYER I.D. NO.ZIP/
Combined Insurance Company of AmericaClaim Department P.O. Box 6700 Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930FRAUD NOTIFICATIONSIf you are a resident of or if the policy was issued in one of the following states, we are required to provide you withthe following Fraud Warning Notification:ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, orconfinement in prison, or any combination thereof.ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containingfalse, incomplete, or misleading information may be prosecuted under state law.ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Anyperson who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal andcivil penalties.ARKANSAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement inprison.CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowinglypresents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement instate prison.COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance companyfor the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial ofinsurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting todefraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reportedto the Colorado division of insurance within the department of regulatory agencies.DELAWARE: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claimcontaining any false, incomplete or misleading information is guilty of a felony.DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purposeof defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may denyinsurance benefits, if false information materially related to a claim was provided by the Applicant.FLORIDA: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or anapplication containing any false, incomplete, or misleading information is guilty of a felony of the third degree.IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claimcontaining any false, incomplete, or misleading information is guilty of a felony.INDIANA: A person who knowingly and with the intent to defraud an insurer files a statement of claim containing any false,incomplete, or misleading information commits a felony.KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statementof claim containing any materially false information or conceals, for the purpose of misleading, information concerning any factmaterial thereto commits a fraudulent insurance act, which is a crime.LOUISIANA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement inprison.MAINE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the Company. Penalties may include imprisonment, fines or a denial of insurance benefits.MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or whoknowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to finesand confinement in prison.MINNESOTA: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement ofclaim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud,as provided in RSA 638:20.NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subjectto criminal and civil penalties.NEW MEXICO: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OFA LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE ISGUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.CIRCE-1 (0320)
FRAUD NOTIFICATIONS CONTINUEDNEW YORK: Any person who knowingly and with intent to defraud any insurance company or other person files an applicationfor insurance or 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, and shall also besubject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.OHIO: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits anapplication or files a claim containing a false or deceptive statement is guilty of insurance fraud.OKLAHOMA: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes anyclaim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files anapplication for insurance or statement of claim containing any materially false information or conceals for the purpose ofmisleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjectssuch person to criminal and civil penalties.PUERTO RICO: Any person who knowingly and with the intention of defrauding presents false information in an insuranceapplication, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit,or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctionedfor each violation with the penalty of a fine of not less than five thousand ( 5,000) and not more than ten thousand ( 10,000),or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, thepenalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may bereduced to a minimum of two (2) years.RHODE ISLAND: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement inprison.TENNESSEE: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.TEXAS: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and maybe subject to fines and confinement in state prison.VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for thepurpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.WASHINGTON: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company forthe purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.WEST VIRGINIA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowinglypresents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement inprison.ALL OTHER STATES: Any person who knowingly and with intent to defraud any insurance company or other persons,files a statement of claim containing any materially false information, or conceals for the purpose of misleading, informationconcerning any fact material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecutionand/or civil penalties.REQUIRED SIGNATURE OF CLAIMANTBy making claim to these proceeds, I declare that all the answers recorded on this statement are true and complete to thebest of my knowledge and belief. I have read the applicable fraud notification statement. I also understand the Companyreserves the right to require or obtain further information, should it be deemed necessary.XCLAIMANT’S SIGNATUREDATEPLEASE PRINT NAMEI signed on behalf of the claimant, as (relationship). If you are thePower of Attorney, Guardian or Conservator, please attach a copy of the document granting authority.If your policy/certificate is paid with pre-tax dollars, benefits paid may be reported to the IRS. Contact your employer regardingreporting requirements.You must sign and date this claim form on the signature line provided on this page. If you do not signthis claim form, we cannot accept your claim submission.CIRCE-1 (0320)
Combined Insurance Company of AmericaClaim Department P.O. Box 6700 Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930CONSENT TO ELECTRONIC TRANSACTIONS, PAYMENTS AND SIGNATURE1. Consent to Electronic TransactionsBy signing and dating this form, you acknowledge, agree and consent to the use by Combined Insurance Company of America(“Combined”) of electronic transactions, electronic signatures, and to the receipt of the electronic version of certain documentsand records, including but not limited to policy delivery, acknowledgements, notices (including, without limitation, privacy notices),forms, invoices, explanation of benefits, proof of loss, claims documentation, releases, authorizations to obtain medical records,affidavits, and disclosures, to the extent permitted by law. Electronic documents will be delivered online to your CombinedSelf-Service Account. You will be notified via email when delivered. This consent unless withdrawn applies to all transactionsbetween you and Combined.You specifically acknowledge as part of your consent that certain documents delivered electronically will contain confidentialinformation and information regarding your personal financial matters (“Personal Financial Information”) and other personallyidentifiable information; and consent to the delivery of such confidential information, Personal Financial Information andpersonally identifiable information by electronic means. The consent that you grant shall remain in effect until withdrawn by you.You specifically acknowledge as part of your consent that we will replace paper delivery of any particular document withelectronic delivery at our sole discretion as electronic delivery of particular documents becomes available and are consentingto delivery of documents to you in the following manner: We may send you email transmitting such documents, whether as textin, attachments to, and/or hyperlinks from such emails. Such emails will be sent to the current email address we have on file foryou. You are responsible for providing us with a valid email address to which you have regular access and you are responsiblefor immediately notifying us of any change of email address. Any change to your email address can be completed through ourSelf-Service portal at https://my.combinedinsurance.com or by calling the Customer Service Department.You have the right to receive communications from Combined in paper form. You may withdraw this consent at any time. Towithdraw your consent, you may call our Customer Service Department at 1-800-225-4500, Monday through Friday between7:30 am and 6:00 pm CST or go to www.combinedinsurance.com/us-en/contact-us to fill out and submit a General Inquiriesform. Your withdrawal will not affect or change in any way the legal effectiveness, validity or enforceability of any documents thatwere delivered to you electronically before your withdrawal became effective.To request a paper copy of any document that was originally provided to you electronically, at no charge, please call ourCustomer Service Department.2. Consent to Electronic PaymentIf you submit a payable claim, Combined may offer you the option to receive your benefit payment electronically via banktransfer into a checking account, transfer into a PayPal account, or transfer to a debit card (as available). Combined will notimpose any fees on you for choosing to accept your payment electronically, but your financial institution may impose a fee orcharge. By signing and dating this form, you are accepting this offer and consenting to accept benefit payments electronically.Consenting to accept payment electronically is voluntary. Your payments received through electronic transfer may be subject toattachment or garnishment if your account is subject to the same.If any portion of your claim is payable, you will receive an email with a link to setup an account and provide the routing andaccount number for the bank or other account where you wish the funds be deposited. If you do not set up an account andprovide the account information within three (3) calendar days, we will automatically issue the payment via a check mailed tothe address on file.Unclaimed funds are subject to the applicable laws concerning unclaimed property.By signing and dating this form, you attest that you are the Principal Insured under the coverage for which your claim wassubmitted.3. Consent to Electronic SignatureYou also agree that your electronic signature is the legal equivalent of your manual signature on the above listed documents.You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or tootherwise agree, acknowledge, consent, opt-in, or certify to any of the above documents constitutes your signature, acceptanceand agreement as if manually signed by you in writing. You agree that no certification authority or other third-party verification isnecessary to validate such signature, and that the lack of such certification or third party verification will not in any way affect theenforceability of such signature or any such document. You represent that you will be bound by the terms of this consent. Thisconsent for electronic delivery and signature is effective until withdrawn by you. Doing business electronically will not affect thevalidity, legal effect or enforceability of any of your transactions with Combined.CIRCE-1 (0320) e-Pay
Combined Insurance Company of AmericaClaim Department P.O. Box 6700 Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930You are responsible for ensuring that neither your software nor your Internet service provider inhibits or interferes with thenotices and communications described herein. To ensure delivery of your policy, claim, and/or other documents, the followingminimum hardware and system requirements are necessary to sign, print, retain and receive such documents.OperatingSystemsWindows 7 or 8.1 or MACBrowsersFinal release versions of Internet Explorer 9.0 or above (Windows only); Firefox 34 or above (Windowsand Mac); Safari 5.0 or above (Mac only); Google Chrome 39 or above; Apple iOS 7 or above; Android4.4 and abovePDF ReaderAcrobat Reader or similar software may be required to view and print PDF filesScreenResolution800 x 600 minimumEnabledSecuritySettingsAllow per session cookiesBy signing and dating this form, you are confirming that your computer or electronic device meets the system requirementsnecessary to print, store and receive claims documents electronically and that you may be able to access such documents forfuture reference.Print NameSignatureE-mail AddressDateCIRCE-1 (0320) e-Pay
Combined Insurance Company of AmericaClaim Department P.O. Box 6700 Scranton, PA 18505-0700 Telephone 1-800-225-4500 Fax 312-351-6930AUTHORIZATION TO OBTAIN AND DISCLOSE INFORMATIONClaim or Policy Number:Name:Doctor’s Name:Address:Hospital’s Name:Birthdate: / /Adm. / /Disch. / /This will authorize COMBINED INSURANCE COMPANY OF AMERICA, PO BOX 6700, Scranton, PA, 18505-0700 to obtainnecessary medical information for the purposes of evaluating my insurance claim. The information to be obtained shall includeinformation from any Prescription Drug Database, all health care providers, employer, consumer reporting agency, any otherinsurance company, or the “MIB” (Medical Information Bureau), which is relevant to my loss or condition being evaluated. Ifurther authorize Combined to rely on this authorization for two years, or as otherwise permitted by law, to disclose informationabout me for purposes of processing my insurance claims, including assistance with return to work.The information to be disclosed may include but is not limited to:History of Present IllnessOperative ReportsDaily Doctor’s NotesX-Ray ReportsConsultant’s ReportPathology ReportsPast Medical HistoryBlood/ToxicologyDischarge SummaryLaboratory ResultsPrevious AdmissionsThe information is needed for the following purpose(s): Evaluation and processing of my insurance claimI und
Statement found in SECTION C on the third page. 5. Have your physician complete SECTION D, the Attending Physician’s Statement, on the fourth page. 6. Review the Fraud Notification for your state on the fifth or sixth page. 7. Sign and date the claim form on the signature line provided at
