Combined Insurance, a Chubb company, uses this 14-page claim for its sickness and short-term disability income policies. A licensed physician completes Section 4, the Attending Physician Statement, documenting the diagnosis, treatment, the dates the patient could not perform job duties and any restrictions. The employer reports job demands, missed work and other income in Section 3, and the claimant submits the full packet online, by mail or by fax.
A licensed physician completes and signs Section 4. The policyholder and claimant complete Sections 1 and 2, an employer HR representative completes Section 3, the claimant signs Section 5 and Sections 7 and 8, and the policyholder completes Section 6 only for electronic payment.
The policyholder enters name, middle initial, date of birth, age, gender, the last four digits of the Social Security number, policy or certificate numbers, address, email and phone. The policy number identifies the coverage, and Combined posts different versions of this form for individual, worksite and New York policies, so the number should match the version being filled out.
The claimant gives other names used, the last date worked, any hospital stay with admission and release dates, and the primary physician's name and contact details. If the disability came from an accident, they add the date, place and how it occurred. They also report any prior episode of the same illness or injury with that physician, whether they are working now and for how many hours, an HR contact, the expected return-to-work date and the next office visit.
An HR representative confirms job title, hire date, weekly hours and pay including commissions and bonuses for the 12 months before the last day worked, and attaches the job description. A grid rates how long the job requires sitting, standing, lifting and other activities, from never to constantly (more than 5.5 hours), with strength levels from sedentary to very heavy. The employer also certifies dates missed, return-to-work status, partial duty, workers' compensation, other disability coverage and, for group plans, continued pay.
Enter the claimant's name, date of birth and any claim or policy number, then the primary diagnosis and other conditions with ICD 9/10 codes. Mark sickness or injury and give the date symptoms first appeared, any accident date and the first consultation date. Answer whether the patient had the same or a similar condition before and whether it arose from employment. For pregnancy, give the due and delivery dates, the delivery type, complications and any NICU admission.
Record the first, most recent and next consultation dates and the release date, and for a sickness the date it was first diagnosed. List diagnostic tests with dates and include supporting documentation of the results. Add any surgical or medical procedure with its date and procedure code, hospital admission and discharge dates, and the current treatment plan. The continued page covers office or urgent care and emergency room visits with dates, facility names and the nature of treatment.
State whether the patient is unable to perform their job duties and give the total disability dates from and through, then the expected dates for partial duties and full duties. Mark restrictions and limitations as temporary, with duration, or permanent, and describe them. In the verification, sign and date, print your name, and add specialty, phone, address, fax, license number and email, certifying that the answers are true, complete and correctly recorded.
The claimant signs and dates this authorization so Combined and ACE Property & Casualty can obtain records from health care providers, prescription drug databases, the employer, other insurers, consumer reporting agencies and the MIB, including for return-to-work assistance. It may cover mental health, HIV and substance use records, expires 24 months after signing and can be revoked in writing. A legal representative attaches documentation of legal status.
The policyholder completes Section 6 with phone, email, signature and date, and both pages are returned only for electronic payment; for a paper check it is left out. Section 7 holds the state fraud warnings. In Section 8 the claimant signs and dates a declaration that all answers are true and complete; a 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.
Sickness/Disability Claim Form
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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A licensed physician completes Section 4 and signs the Attending Physician Verification, certifying that the answers are true, complete and correctly recorded. The verification also asks for a printed name, specialty, contact details and license number. Combined will not accept a claim submission unless all applicable signature boxes are signed and dated.
The physician states whether the patient is unable to perform their job duties and, if so, the total disability dates from and through. Section 4 then asks when the patient is expected to resume part-time or partial duties and full-time or full duties, and whether restrictions are temporary, and for how long, or permanent.
Section 4 includes fields for pregnancy or complications of pregnancy: the due date, the delivery date, whether the delivery was normal or by C-section, any complications, and whether the baby was admitted to the NICU, with dates. The same section records diagnostic tests, procedures, hospital stays and the current treatment plan.
Section 3 has a box for self-employed claimants, who check it and then complete and sign the employer's statement themselves. Combined notes it may require proof of income and will say if more documents are needed. Unemployed claimants check a separate box and give their last date worked and prior employer's name.