Critical Illness and Wellness Benefit Claims

You may be eligible to receive a Critical Illness Benefit and/or a Wellness Benefit under your Critical Illness Insurance certificate. Please review your certificate and riders for the eligibility requirements to receive benefits.

To submit a Critical Illness Insurance Claim, please print the following forms below:

  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: Please contact your Employer to determine whether the Critical Illness Claim – Employer form is required.

Submit the completed and signed claim form, attending physician's statement, and authorization form to the address shown at the top of the form.

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)

To submit a Wellness Benefit Rider Claim:

Please print the Critical Illness Insurance Wellness Benefit Rider Claim form below. The Consumer Privacy Notice is attached.

Submit the completed and signed form to the address shown at the top of the form, along with any other required information such as itemized bill(s) or Explanation of Benefits (EOB).

Form NameForm Number

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

166587 (01/24/2013)

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