Combined Insurance, a Chubb company, uses this 11-page claim for critical illness and specified disease benefits. The claimant picks the condition from a list running from heart attack and stroke to cancer, organ transplant and childhood conditions. The attending physician completes Section 3, confirming the diagnosis, ICD code, date of diagnosis, treatment and any work restrictions.
The policyholder and claimant complete Sections 1 and 2, and the claimant signs the authorization and the required signature section. The licensed attending physician completes and signs Section 3, including specialty and license number.
Download the current version from the source each time; forms change without notice.
Critical Illness Claim Form
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Section 3 asks for the primary diagnosis and ICD code, sickness or injury, symptom onset, first consultation, diagnosis date, tests with results, procedures with codes, hospitalization, the treatment plan, and dates the patient was unable to work. The physician signs with specialty and license number.
Yes. The checklist asks the claimant to attach proof such as emergency records, medical records, office notes, test results, pathology or operative reports, discharge summaries, itemized bills and confirmation of dialysis. Combined may also contact the treatment provider if more information is needed.
Yes. Combined posts a New York version and a worksite version alongside the individual 'Signature' version, all under form number CI-CLM-CI. Use the version that matches how the patient's policy was issued and paid for.