Critical Illness and Wellness Benefit Claims

Critical Illness Insurance Claim

Please distribute the following forms to the insured.

  1. Critical Illness Claim form. The Consumer Privacy Notice is attached
  2. Attending Physician's Statement of Critical Illness
  3. Authorization to Release Information
  4. Critical Illness Claim – Employer form. The Consumer Privacy Notice is attached.
    Note: If the Employer has submitted enrollment data electronically, this form does not need to be completed.
Form NameForm Number

Critical Illness Claim Employee (with Consumer Privacy Notice 47316c attached)

160045 (02/01/2013)

Attending Physician's Statement of Critical Illness

126171 (02/01/2013)

Authorization to Release Information

132542 (09/30/2009)

Critical Illness Claim – Employer (with Consumer Privacy Notice 47316c attached)

165222 (02/01/2013)

Wellness Benefit Claim

Please distribute the claim form to the insured. The Consumer Privacy Notice is attached.

Form NameForm Number

Critical Illness Insurance Wellness Benefit  Employee (with Consumer Privacy Notice 47316c attached)

166587 (01/24/2013)

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