Holders of an accident policy from Combined Insurance, a Chubb company, file this 11-page claim after an accidental injury. A licensed physician completes Section 3, the Attending Physician Statement, recording the diagnosis with ICD codes, treatment dates and any period the patient could not do their job. The claimant attaches proof of injury such as itemized bills and medical records, then submits the packet online, by mail or by fax.
A licensed physician completes Section 3 and signs its Attending Physician Verification. The policyholder and claimant complete Sections 1 and 2, the claimant signs the Section 4 authorization and Section 7, and the policyholder signs Section 5 only to receive electronic payment.
The policyholder gives name, policy or certificate numbers, date of birth, age, gender, the last four digits of the Social Security number, address, email and phone. If the claim is for someone other than the policyholder, check Yes, mark the relationship (spouse, domestic partner or civil union partner, child or stepchild) and enter the dependent's name, other names used, date of birth, last four Social Security digits and contact details.
The claimant records the accident date, the date of the initial exam and the medical provider's name and address, then answers whether the same kind of injury happened before, whether it occurred at work, whether workers' compensation covers it and whether it was sport related. Hospital, ICU and rehabilitation hospital stays each need the facility name and admission and discharge dates, followed by any ground or air ambulance transport and a brief description of how the accident happened and the injury sustained.
Enter the claimant's name, date of birth and claim or policy number if available, then the primary diagnosis and other conditions with ICD 9/10 codes. Mark whether the condition is a sickness or an injury and give the date symptoms first appeared, the accident date and the date the claimant first consulted you. Answer whether the patient had the same or a similar condition before and whether it arose from employment. Pregnancy fields cover due and delivery dates, delivery type, complications and NICU admission.
Give the first, most recent and next consultation dates and the release date, plus the date a sickness was first diagnosed. For diagnostic testing, list the tests and dates and include supporting documentation of the results. Record any surgical or medical procedure with its date and procedure code, any hospitalization with admission and discharge dates and the hospital, and the current treatment plan. The continued page adds office or urgent care and emergency room visits, each with date, facility and nature of treatment.
State whether the patient is unable to perform their job duties and, if so, the total disability dates from and through. Give the expected dates for resuming part-time or partial duties and full-time or full duties. Mark the restrictions and limitations as temporary, with how long, or permanent, and describe the current restrictions. These answers document any time the patient was unable to work because of the accident.
The physician certifies awareness that it is a crime to fill out the form with facts known to be false or to leave out relevant and important facts, and that the answers are true, complete and correctly recorded. Sign and date, then print your name and add specialty, phone, address, fax, license number and email. Combined cannot accept a claim unless every applicable signature box is signed and dated.
The claimant, or a parent or guardian, signs and dates this authorization, which lets Combined and its affiliate ACE Property & Casualty obtain information from prescription drug databases, all health care providers, the employer, other insurers and the MIB. Listed records include history of present illness, consultant and pathology reports, x-ray and lab results, daily doctor's notes and discharge summaries. It expires 24 months after signing and may be revoked in writing. A legal representative attaches documentation of legal status.
Section 5 is returned only if the policyholder wants electronic payment and documents, and both of its pages must be included; for a paper check it is left out. Section 6 lists the state fraud warnings. In Section 7 the claimant signs and dates a declaration that all answers are true and complete. Anyone signing as power of attorney, guardian or conservator attaches the document granting that authority.
Download the current version from the source each time; forms change without notice.
Accident Claim Form
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Sources for this guide
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The form's checklist says Section 3, the Attending Physician Statement, is to be completed by a licensed physician. The physician signs a verification certifying that the answers are true, complete and correctly recorded, and adds a printed name, specialty, contact details and license number below the signature.
Yes, when it applies. Section 3 asks whether the patient is unable to perform their job duties, the total disability dates, when part-time or partial duties and full duties are expected to resume, and whether restrictions and limitations are temporary, and for how long, or permanent, with a description of the current restrictions.
Yes. The checklist asks claimants to attach proof of injury, such as emergency records, itemized bills, the hospital's UB-04 bill, medical records, imaging and physical therapy reports. Section 3 also asks the physician to include supporting documentation for any diagnostic test results reported on the form.
Yes. Combined's Policyholder Center posts a New York version for individually owned policies and a worksite New York version for employer group policies whose numbers start with C. Policy numbers starting with W use the non-New York worksite form, so check the policy number before choosing a version.