Hospital Confinement Indemnity Claims

Hospital Confinement Indemnity Insurance Claim

Please distribute the following forms to the insured.

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

Compass Hospital Confinement Indemnity Claim - Employee (with Consumer Privacy Notice 47316c attached) for group policies issued in all states except New York

167313 (2/7/14)

Attending Physician's Statement of Hospital Confinement Indemnity for group policies issued in all states except New York

167314 (2/7/14)

Authorization to Release Information

132542 (09/30/2009)

Hospital Confinement Indemnity Claim - Employer for group policies issued in all states except New York

167546 (2/7/14)

Wellness Benefit Claim

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

Form NameForm Number

Wellness Benefit Rider Claim - Employee (with Consumer Privacy Notice 47316c attached) for group policies issued in all states except New York

165760 (07/01/2014)