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Navigating the Disability Claim form can seem overwhelming at first, but understanding its components can simplify the process significantly. This form is essential for individuals seeking benefits under a continuing disability policy. It includes several critical sections: the Claimant Statement, which gathers information from the policy owner about their personal details and the nature of their disability; the Employer Statement, completed by the claimant's employer to confirm employment status and duties; and the Physician Statement, where the healthcare provider outlines the medical condition that limits the claimant's ability to work. Each section must be meticulously filled out to ensure a smooth claims process, and any missing or illegible information can lead to delays. In addition, optional services such as overnight delivery for claims payments and updates via automated messages are available, adding convenience for the claimant. A fraud warning appears throughout the document, reminding individuals of the legal implications associated with false information. Therefore, accuracy and completeness are paramount in ensuring that claims are processed efficiently and correctly.

Form Sample

Colonial Life & Accident Insurance Company, Columbia, SC | CONTINUING DISABILITY | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Continuing Disability Claim

FAX this direction

FAX this form: 1-800-880-9325

Or mail: P.O. Box 100195, Columbia, SC 29202

From:

Number of pages:

Submit Additional Information Online

uSimply log into your account at Coloniallife.com and click on the claim number to add additional information. You will be able to upload the form after it has been completed by the employer and/ or the physician.

uIf you did not select direct deposit when you initially submitted the claim, go to the My Profile page on your account and select direct deposit. You will also need to call our Contact Center to have the information added to the current claim.

uNot a member? Log onto Coloniallife.com and click on "Register" then "Join the Policyholder Website" to set up your account.

Optional Service Release Agreement

Please indicate below for optional services you desire. Any marks used (check mark, X, initials, etc.) will be considered as your authorization and will be processed as if they were selected.

I authorize Colonial Life to facilitate processing this claim by releasing its details to the following individual(s) inquiring on my behalf. Note: Leave blank if you do not want anyone accessing your claim information.

______ Sales representative ______ Employer ______ Spouse, family member or significant other Name: _________________________

______ I want Colonial Life to update me on the status of my claim through prerecorded messages at my contact number indicated on this

form. I understand that messages will be left with anyone who answers the phone or on my answering machine. Note: To avoid blocked calls, you should program the number 1-800-325-4368 into your phone.

______ Yes, I want ALL payment(s) for this claim sent by overnight delivery. I understand payment(s) under $100.00 cannot be sent overnight.

I also understand that if I want my claim to be sent by overnight delivery, a $22.00 fee will be deducted from my claim payment. This fee is subject to rate increases by carrier and does not include weekend or holiday delivery. I understand that Colonial Life is unable to send overnight mail to a P.O. Box.

I also understand that I must notify Colonial Life to discontinue any of these services.

Do not use this form if filing for injury or sickness for the first time.

Complete each section before submitting your claim. Incomplete claim form submission may result in a delay in the processing of your claim.

Please make sure that all written responses are legible.

Section 1 – Claimant statement (completed by policy owner)

Claimant name:

£Male £Female

DOB: ____ /____ /______

SSN:

Relationship to policy owner: £Self £Spouse

£Domestic partner £Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy owner information

Name:

 

 

 

DOB: ____ /____ /______

SSN:

(if other than claimant)

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

Apt. #

City:

 

State:

 

ZIP:

 

 

 

 

 

 

 

 

 

Email:

 

 

 

 

Contact number:

 

 

 

 

 

 

Home/Cell/Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claim is for: £Accident £Sickness

 

Date the accident occurred (not when it was treated): ______ /______ /_________

 

 

 

 

 

 

 

 

 

 

 

Condition that keeps you from working:

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

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| ColonialLife.com | 7-20 | 46988-28

Colonial Life & Accident Insurance Company, Columbia, SC | CONTINUING DISABILITY | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Claim Fraud Statements

For your protection, the laws of several states, including Alaska, Arkansas, Delaware, Idaho, Indiana, Louisiana, Minnesota, New Hampshire, Ohio, Oklahoma, and others, require the following statement to appear on this claim form. Fraud Warning: Any person who knowingly, and with intent to injure, defraud, or deceive an insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of insurance fraud, which is a felony.

Alabama: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly present false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof.

Arizona: For your protection Arizona law requires the following

statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

California, Rhode Island, Texas and West Virginia: For your protection, California, Rhode Island, Texas and West Virginia law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance 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 to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

District of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance 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 an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky: For your protection, Kentucky law requires the following to

appear on this form: 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.

Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose 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 who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

New Jersey and New Mexico: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for 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 be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for 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 subjects such person to criminal and civil penalties

Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, 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 sanctioned for each violation with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, the penalty thus established may be increased to a maximum of five (5) years; if extenuating circumstances are present; it may be reduced to a minimum of two (2) years.

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

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| ColonialLife.com | 7-20 | 46988-28

Colonial Life & Accident Insurance Company, Columbia, SC | CONTINUING DISABILITY | Fax: 1-800-880-9325 | Telephone: 1-800-325-4368

Claimant name:

Claimant SSN:

Section 1 – Claimant statement ~ continued (completed by policy owner)

Have you been unable to work?: £ Yes £ No If yes, list the dates unable to work: From: _______ / _______ / ________ To: _______ / _______ / ________

Date returned to work: Full-time: ______ / _______ / _________ Part-time: ______ / _______ / _________ Hours worked per week: ____________

If not employed

List dates of house confinement: From: ______ / _______ / _________ To: ______ / _______ / _________

House confinement means you are kept at home (in house or yard) by the condition. However, you may follow physician's orders, even if it means leaving home.

Have you been unable to perform activities of daily living? £Yes £No

If yes, list dates: From: ______ / _______ / _________ To: ______ / _______ / _________

Check activities of daily living that you are unable to perform: £Dressing

£Eating £Meal preparation £Bathing £Transferring £Toileting £Continence

Certification

Policy owner’s name: _________________________________________________________________________ SSN: _________________________

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 two 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.

____________________________________________________

____________________________________________________

______________________________

Print claimant’s name

Claimant’s signature

Date

____________________________________________________

____________________________________________________

______________________________

Print policy owner’s name

Policy owner’s signature

Date

Section 2 – Employer statement (completed by employer)

Employee name:

 

 

 

 

 

 

Employee title:

 

 

 

 

 

 

 

 

 

 

 

 

Average number of scheduled hours per week:

 

Date last worked: _____ / _____ / ________

Date employment terminated: _____ / _____ / ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was the employee at work when accident or sickness occurred? £Yes £No

 

 

Was a workers’ compensation claim filed? £Yes £No

 

 

 

 

 

 

 

 

 

Workers’ compensation carrier:

 

 

 

 

 

Telephone:

 

 

 

 

 

Employee unable to work (Full-time): From:________ / _______ / ___________ To: ________ / _______ / ___________

 

 

 

 

 

 

 

 

 

 

 

Do you permit light duty for employee? £Yes £No

 

Do you permit partial duty for employee? £Yes £No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Actual return to work

 

 

 

Actual return to work

 

Expected return to work: _______ / ______ / ________

Full-time: _______ / ______ / ________

Part-time: _______ / ______ / ________ Hours per week:________

 

 

 

 

 

 

 

 

 

Employee’s

 

£ Sitting _____ per hr. £ Walking _____ per hr. £ Climbing stairs/ladders _____ per hr. £ Standing _____ per hr. £ Driving _____ hrs. per day

duties

 

 

 

 

 

 

 

 

 

 

 

include:

 

Lifting: £ Less than 15 lbs. £ 15 to 44 lbs. £ More than 45 lbs.

Stooping/bending: £ none £ seldom £ frequent

 

 

 

 

 

 

 

 

 

 

 

 

Contact for updates on return to work status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fraud warning: Any person who knowingly files a statement of claim containing false or misleading information is subject to

 

 

criminal and civil penalties. This includes employer’s portions of the claim form.

 

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________________________________________

 

______________________________

 

 

 

 

 

Signature of authorized person

 

 

 

 

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

Title of authorized person signing:

 

 

 

 

Employer/company name:

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

Fax:

 

 

Email:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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| ColonialLife.com | 7-20 | 46988-28

Colonial Life & Accident Insurance Company, Columbia, SC | CONTINUING DISABILITY |

Fax: 1-800-880-9325

| Telephone: 1-800-325-4368

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Claimant SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 3 – Physician statement (completed by physician)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB: _____ / _____ / _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is condition due to an accidental injury? £Yes £No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

What diagnosis prevents the patient from working? (If pregnancy, list complications.)

 

 

 

 

 

 

 

 

 

 

 

 

Date first treated for this diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______ / ______ / ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are there any secondary diagnoses preventing the patient from working? £Yes £No

Secondary diagnoses:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When did symptoms first appear?

 

Date of new patient consultation:

 

Symptoms:

 

 

 

 

 

 

 

 

 

 

 

 

______ / ______ / _________

 

______ / ______ / _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current treatment plan:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List any test performed (submit copy of test results):

 

 

 

 

 

 

 

List any surgeries performed (submit copy of operative report):

 

 

Date: _________ / _________ / ___________

CPT code: ________________

 

 

 

Date: _________ / _________ / ___________

CPT code: ________________

 

Date: _________ / _________ / ___________

CPT code: ________________

 

 

 

Date: _________ / _________ / ___________

CPT code: ________________

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of patient’s last visit:

 

 

 

 

Date of next scheduled visit:

 

 

 

How soon do you expect significant improvement in the patient’s medical condition?

 

______ / ______ / _________

 

 

 

 

______ / ______ / _________

 

 

 

 

£1 - 2 months

£3 - 4 months

£5 - 6 months

£more than 6 months

 

 

 

 

 

 

 

 

 

 

 

Does patient have permanent restrictions and/or limitations? £Yes £No

 

 

 

 

Limitations (patient CANNOT DO):

 

Restrictions (patient SHOULD NOT DO):

 

If yes, which ones are permanent:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates unable to work (full-time):

From: _____ / ______ / ________

To: _____ / ______ / ________

 

Expected return to work: _____ / ______ / ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates able to work (part-time):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

From: _____ / ______ / ________ To: _____ / ______ / ________

Number of hours: ___________

 

Actual return to work (full time): _____ / ______ / ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did this condition require house confinement?: £Yes £No

If yes, From: ______ / ______ / _________ To: ______ / ______ / _________

 

 

 

 

House confinement means the patient is kept at home (in house or yard) by the condition. However, the patient may follow your orders, even if it means leaving home.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check activities of daily living that the patient is unable to perform: £Dressing

£Eating £Meal preparation

£Bathing

£Transferring £Toileting £Continence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dates unable to perform activities of daily living: From: _____ / _____ / ________

To: _____ / _____ / ________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date(s) of hospitalization (last 3 months):

 

 

 

 

 

 

 

 

 

Date(s) of office visit (last 3 months):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you referred patient to a specialist? £Yes £No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hospital:

 

 

 

 

 

 

 

 

 

 

 

Specialist:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

State:

 

ZIP:

 

 

 

Address:

 

 

 

 

 

 

 

State:

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

Fax:

 

 

 

 

 

 

 

Telephone:

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREGNANCY

 

 

Date of delivery: _______ / _______ / __________

 

 

 

Type of delivery: £Vaginal

£C-section

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fraud warning: Any person who knowingly files a statement of claim containing false or misleading information is subject to

 

criminal and civil penalties. This includes Attending Physician portions of the claim form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_________________________________________________________________________________________

 

 

 

___________________________________

 

 

 

 

 

 

 

Physician signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date (MM/DD/YYYY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician/group name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient account number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s specialty:

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tax ID or SSN:

 

 

 

 

 

 

 

 

 

 

 

Do you accept medical record requests by fax?

£Yes £No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you require a special authorization for release of information? £Yes £No

 

Patient Portal £Yes £No

 

Will you accept the standard HIPAA release?

£Yes £No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was patient referred to you by another physician? £Yes £No

 

 

 

Authorization on file to release information to Colonial Life: £Yes

£No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring physician:

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

ZIP:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

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| ColonialLife.com | 7-20 | 46988-28
⇩ PDF

Document Specifications

Fact Name Detail
Submitting the Form The Disability Claim form can be submitted via fax to 1-800-880-9325 or mailed to P.O. Box 100195, Columbia, SC 29202.
Online Information Claimants can log into their account at Coloniallife.com to add additional information related to their claim.
Direct Deposit Option To opt for direct deposit after initial submission, claimants must update their My Profile page and call the Contact Center.
Claim Fraud Statement The form includes a Fraud Warning, advising that providing false information is a crime punishable under various state laws.
Patient's Condition Claimants must specify whether their condition is due to an accident or an illness, detailing dates and the nature of their disability.
Employer's Responsibilities The section completed by the employer verifies the employee's work status, including any claims made under workers' compensation.
Physician's Statement The physician must provide a diagnosis that prevents the patient from working, along with details of treatment and expected recovery time.
Contact for Updates Claimants can designate individuals to receive updates regarding the status of their claims, ensuring their privacy choices are respected.
Additional Services Options for updates and overnight delivery of benefits are available, but fees may apply for expedited services.
State Specific Laws States such as Florida and California have specific legal language regarding fraudulent claims that must appear on the form.

Steps to Filling Out Disability Claim

Completing the Disability Claim form is an important step in ensuring that your claim is processed efficiently. Carefully follow the instructions to fill out the required sections accurately. Incomplete submissions may cause delays in processing your claim.

  1. Begin with Section 1 – Claimant statement. Fill in your name, date of birth, and Social Security Number (SSN).
  2. Indicate your relationship to the policy owner and provide the policy owner's information, including name, date of birth, and SSN (if applicable).
  3. Complete your contact information, including address and phone number.
  4. Check whether the claim is for an accident or sickness, and provide the date the event occurred and the condition preventing you from working.
  5. Indicate if you have been unable to work, and if so, list the dates you were unable to work.
  6. Provide the date you returned to work, noting whether it was full-time or part-time, and include your weekly hours.
  7. If not employed, list the dates of house confinement.
  8. Answer whether you have been unable to perform activities of daily living and provide dates.
  9. Identify which activities you are unable to perform by checking the appropriate boxes.
  10. Sign and date the certification statement, including both the claimant’s name and policy owner’s details.
  11. Next, Section 2 – Employer statement must be filled out by your employer. Provide the employee’s name, title, and average hours worked.
  12. Indicate the dates last worked and if employment has been terminated, along with answers to relevant questions regarding injury or sickness.
  13. Your employer will complete sections related to the employee’s ability to perform duties, including whether light and partial duty are permitted.
  14. Finally, Section 3 – Physician statement must be filled out by your physician, including the patient’s information and diagnosis. The doctor will provide detailed insights about the treatment process and expected recovery timeline.
  15. Ensure your physician completes all requested information, signs, and dates the form.

Once the form is completed, you may submit it by faxing it to the provided number or mailing it to the specified P.O. Box. Ensure that all written responses are clear and legible to avoid any processing delays.

More About Disability Claim

What is the process for submitting a Disability Claim form?

To submit a Disability Claim form, you have two options: faxing or mailing the completed form. If you choose to fax, send it to 1-800-880-9325. For mailing, send the form to P.O. Box 100195, Columbia, SC 29202. Ensure you have completed all required sections of the form before submission to avoid delays.

How can I provide additional information after submitting my claim?

You can easily submit additional information online by logging into your account at Coloniallife.com. Once logged in, click on your specific claim number to upload any extra documents or information needed. Make sure that any additional information is relevant and aligned with your initial claim to prevent any processing delays.

What should I do if I want my claim payment sent via direct deposit?

If you didn’t select direct deposit initially, you can enable it by visiting the My Profile page on your Colonial Life account. After making this selection, you also need to contact the Customer Support Center to link this option to your current claim. Having direct deposit ensures that your payments are processed more quickly.

Are there any fees associated with receiving a claim payment by overnight delivery?

Yes, if you choose to have your payment sent by overnight delivery, a fee of $22.00 will be deducted from your claim payment. Note that payments under $100.00 cannot be sent overnight. Additionally, Colonial Life cannot send overnight deliveries to a P.O. Box. Remember to provide a physical address to avoid any delivery issues.

What constitutes incomplete information on the Disability Claim form?

Incomplete information refers to any missing sections of the form or any illegible responses. This includes not providing your Social Security number, signature, or failing to answer all questions. To expedite the claims process, make sure that all sections are filled out clearly and accurately before submitting.

Common mistakes

Filling out a Disability Claim form correctly is crucial to ensure a smooth processing experience. However, many individuals make common mistakes that can delay their claims. Here is a list of eight frequent errors encountered during the completion of the form:

  1. Failing to review the form thoroughly before submission. Incomplete or incorrect entries can lead to processing delays.
  2. Not ensuring that all written responses are legible. Handwriting that is difficult to read may cause misinterpretation of the provided information.
  3. Omitting vital dates related to the condition or treatment. Accurate dates are essential for assessing the claim.
  4. Not providing complete contact information. Missing phone numbers or emails can hinder communication and updates about the claim status.
  5. Neglecting to include any necessary medical documentation that supports the claim. This documentation strengthens the case for disability and should be attached as needed.
  6. Misunderstanding the definition of house confinement. It's vital to clearly state any conditions that prevent attendance at work to avoid delays in claim approval.
  7. Using incorrect authorization marks. When designating individuals authorized to receive updates, ensure selections are clearly marked to prevent misunderstandings.
  8. Submitting the form without proper signatures. The failure to include the claimant’s and policy owner’s signatures can result in immediate rejection of the claim.

Attention to detail can significantly impact the processing of disability claims, ensuring that all information is accurate and complete facilitates a quicker resolution and less frustration for all parties involved.

Documents used along the form

When filing a disability claim, several additional forms and documents may be required to ensure a smooth and efficient process. Each serves a specific purpose to support the claim and provide necessary information. Below are some common forms and documents you may encounter alongside the Disability Claim form.

  • Employer Statement: This form is completed by the employer and provides details about the employee's job, hours, and any accommodations for light or partial duty work. It verifies the employment status and helps confirm the reasons for the claim.
  • Physician Statement: This document, filled out by the treating physician, outlines the medical condition and details the treatment plan. It includes information about diagnoses, limitations, and expected return dates, which substantiates the claim.
  • Authorization to Release Information: This form allows the insurance company to obtain medical records or other necessary information from healthcare providers. It is crucial for verifying the details surrounding the disability claim.
  • Optional Service Release Agreement: This agreement allows individuals to indicate whether they authorize Colonial Life to share claim information with specified people, such as family members or employers, facilitating smoother communication regarding the claim.
  • Direct Deposit Authorization: If you want your payments deposited directly into your bank account, this document must be completed. It streamlines the payment process and avoids delays related to check delivery.
  • Proof of Income Documentation: Some claims may require past income statements, pay stubs, or tax returns to determine how much the claimant was earning prior to the disability. This information aids in calculating the benefits owed.
  • Claim Fraud Statements: These statements inform claimants about the legal consequences of providing false information on the claim. Signatures acknowledging the fraud warning are typically required on these statements.
  • Additional Information Form: This optional form allows claimants to provide any further details that could support their claim. Supplementing the initial claim with additional information can expedite the process.

Gathering these forms and documents thoroughly aids in the efficient processing of a disability claim. Ensure they are completed accurately to avoid any delays or complications in receiving benefits.

Similar forms

The Disability Claim form shares similarities with the Health Insurance Claim form. Both documents require a detailed account of the circumstances surrounding a medical condition and its impact on the individual's ability to work or perform daily activities. Just like the Disability Claim form, the Health Insurance Claim form mandates the submission of patient identification details, the nature of the condition, and supporting information from medical providers to process claims correctly and efficiently.

Another closely related document is the Workers' Compensation Claim form. This form is used when an individual suffers an injury or illness related to their job. Similarly, both forms seek to establish the connection between the medical issue and the inability to work. Each requires specific dates indicating when the injury occurred and when the employee was last able to work, ensuring a clear timeline necessary for compliance and approval.

The Family Medical Leave Act (FMLA) Certification form is also similar. Both the FMLA form and the Disability Claim form focus on health-related matters and the individual's ability to work. While the FMLA form is primarily concerned with leave entitlements, it requires medical verification and documentation, paralleling the requirements for providing proof of disability and medical conditions in the Disability Claim form.

Additionally, the Social Security Disability Insurance (SSDI) application shares common traits with the Disability Claim form. Like the Disability Claim form, the SSDI application requests extensive details about the applicant's medical conditions and work history. Both documents aim to validate an individual's claim for benefits, relying heavily on accurate medical records and careful documentation from healthcare providers.

Similarly, the Long-Term Disability Claim form has much in common with the Disability Claim form. Both documents are meant to secure benefits for individuals unable to work due to ongoing medical issues. They often require similar information, such as medical diagnosis, treatments, and the impact on daily living and work capabilities. Completion in both cases is crucial, as incomplete submissions may result in delays or denials.

The Short-Term Disability Claim form is another related document. It has a similar purpose—providing financial assistance to individuals temporarily unable to work due to illness or injury. Both forms focus on the applicant's condition, and both may require input from healthcare professionals to authenticate the claim. Accuracy and thoroughness in completion are paramount to avoid complications in processing claims.

Next, the Health Care Provider Letter serves a related function. While it may not be a formal claim form, it documents the physician's assessment and can support a Disability Claim. It often includes details about the diagnosis, treatment plan, and expected recovery timeline, providing essential context regarding the claimant's inability to work, just like the Disability Claim form requires.

Insurance Policyholder Forms are also akin to the Disability Claim form. These documents summarize the terms and conditions of the insurance coverage, detailing what is required for a claim to be valid. Both forms emphasize the need for proper documentation, accuracy, and compliance with policy stipulations to ensure that claims are processed swiftly without complications or misunderstandings.

The Residual Disability Claim form is similarly focused on providing benefits to individuals who experience a partial inability to work due to disability. Both forms assess the extent of the disability and its effect on employment. Validation from medical professionals is critical in both cases, as it directly influences the outcome of the disability claim being filed.

Lastly, the Critical Illness Claim form is similar as it addresses claims based on the diagnosis of life-altering conditions. The requirement for clear medical input, detailed account of the illness, and how it affects the individual's life mirrors the aspects of the Disability Claim form. Both forms highlight the importance of a medical professional's signature and support to validate the claim for benefits effectively.

Dos and Don'ts

When filling out the Disability Claim form, keep in mind the following dos and don'ts:

  • Do: Complete every section of the form thoroughly.
  • Do: Ensure that all written responses are clear and easy to read.
  • Do: Submit any additional information required for your claim through the Colonial Life website.
  • Do: Keep a copy of the completed form for your records.
  • Don't: Leave any sections blank; incomplete forms may delay the processing of your claim.
  • Don't: Provide false or misleading information; this can lead to severe penalties.
  • Don't: Forget to sign the form; an unsigned claim could be rejected.
  • Don't: Use this form for an initial injury or sickness claim if it’s your first time filing.

Misconceptions

  • Filing Online is Not Permitted: Many believe they must submit a paper form. In reality, additional information can be submitted online through your account at Coloniallife.com.
  • Direct Deposit is Mandatory: There’s a misconception that direct deposit will automatically be set up with every claim. If not chosen initially, you can opt for it later by updating your profile.
  • A P.O. Box is Acceptable for Overnight Delivery: Some think they can receive payments sent via overnight mail to a P.O. Box. However, payments must be sent to a physical address.
  • Incomplete Forms are Automatically Disqualified: While it’s true that incomplete submissions may delay processing, it's often possible to rectify the issues if you follow up promptly.
  • Claim Fraud Statements are Optional: Many assume they can ignore the fraud statements. In truth, acknowledging these statements is a crucial part of the claim process.
  • Claims Do Not Need Employer Verification: Some individuals think they can submit their claims without employer input. However, the employer’s statement is vital for the claim's approval.

Key takeaways

  • Complete Every Section: Ensure that all sections of the Disability Claim form are filled out completely before submission. Incomplete forms may delay processing.
  • Legibility Matters: All written responses must be clear and legible to avoid any confusion or misinterpretation.
  • Verification Required: The policy owner must sign the form to certify the accuracy of the information provided.
  • Submit Additional Information: If needed, log into your account at ColonialLife.com to add further details once the claim has been initiated.
  • Direct Deposit Option: If direct deposit was not selected initially, visit the My Profile page on your account to update this information.
  • House Confinement Details: Clearly state any periods of house confinement, as it may be required for your claim.
  • Medical Documentation: Ensure that the physician completes their section, including diagnosis and treatment plans, to support your claim.
  • Claim Fraud Information: Be aware of the fraud warnings included in the claim form. Providing false information can lead to criminal penalties.
  • Delivery Preferences: If you wish to receive claims payments by overnight delivery, indicate this on the form; special fees may apply.
  • Contact Information: Provide accurate contact details for both yourself and your employer to facilitate communication during the claims process.