Colonial Life pays accident-policy benefits when a policyholder or covered dependent has a covered accident, and this seven-page paper claim is the alternative to filing online. Section 4, the physician statement, is needed when the patient cannot provide an itemized bill showing diagnosis and procedure codes; the treating physician then records ICD codes, treatment dates and CPT codes and signs. The form goes to Colonial Life by fax or mail.
The treating physician completes and signs Section 4. The policy owner completes Sections 1 and 2 and the certification, the employer completes Section 3 only for an on-the-job injury, and the insured signs the HIPAA authorization on page 7.
Page 1 asks for dates in month/day/year format, legible answers and every section completed, since an incomplete claim may delay processing; a name change needs legal documentation. The policy owner then gives the claimant's name, sex, date of birth, Social Security number and relationship to the policy owner, the owner's details if different, the last day worked, dates unable to work, whether there is a Colonial Life disability policy, and employer contact details.
The policy owner attaches itemized bills from the physician, ambulance, emergency room, hospital or rehabilitation unit that show diagnosis information and procedure codes, plus the operative report if surgery was performed. They give the date the accident occurred rather than when it was treated, on-job or off-job status with any Report of Injury, workers' compensation status, prior treatment for the same condition, hospital dates, a description of the accident and any police report, then list the treating, primary and referring physicians.
The claimant and policy owner print their names, sign and date, and the policy owner certifies under penalty of perjury that the Social Security number is correct and that they received the Claim Fraud Statements on pages 2 and 3. A fraud notice on the same page states that knowingly filing false or misleading information carries criminal and civil penalties, and that this includes the physician statement portion of the claim form.
Only for an injury on the job, an authorized employer representative enters the date the accident occurred and a description of the accident, then signs and dates with title, company name and contact details. The section carries its own fraud warning covering the employer's portion of the claim form.
The section opens by asking for a copy of the doctor's itemized bill with diagnosis and procedure codes; if one cannot be provided, the treating physician completes and signs this section. Enter diagnosis ICD codes, whether an X-ray was taken, whether the condition is due to an accidental injury and the acute injury date, whether it resulted from employment, a description of the injury, any re-injury dates and descriptions, and the office visits related to the accident.
Record hospital admission and discharge dates and times, intensive care and sub-acute intensive care dates, and the hospital. For surgery, mark inpatient or outpatient and hospital, surgery center or doctor's office, with each date and CPT code; diagnostic procedures also need dates and CPT codes. For burns, give second- or third-degree status with percent of total body surface area or square inches, and whether skin grafts were required, attaching the operative report.
Attach the ER report or itemized bill if the patient was treated in the emergency room. Indicate referrals to physical, speech, occupational, acupuncture or alternative therapy, with the facility or prescribed frequency, and any referral to behavioral health therapy. Only if the patient is also covered under a disability policy, give dates unable to work full-time, part-time dates and hours, and the expected and actual return-to-work dates.
Sign and date, then give the physician or group name, patient account number, specialty, contact details and Tax ID or SSN. The form also asks whether your office accepts electronic authorizations, medical record requests by fax, a patient portal or the standard HIPAA release, whether a special authorization is required, whether an authorization to release information to Colonial Life is on file, and the referring physician's details.
The insured signs this HIPAA authorization so providers, health plans, pharmacy benefit managers, the MIB and others can release the entire medical record, excluding psychotherapy notes, to Colonial Life. It is valid for two years or the duration of the claim, whichever is earlier, and a copy is as valid as the original. A guardian, power of attorney or personal representative who signs attaches the document granting authority.
Download the current version from the source each time; forms change without notice.
Accident Claim
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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Not always. The form asks the claimant to submit a copy of the doctor's itemized bill showing the diagnosis and procedure codes. Only if an itemized billing statement cannot be provided does the treating physician complete and sign Section 4, the physician statement.
Section 4 asks for diagnosis ICD codes, then a CPT code and date for each surgery and diagnostic procedure. It also asks whether an X-ray was taken, whether surgery was inpatient or outpatient, and whether it was performed in a hospital, surgery center or doctor's office.
Yes. The form and Colonial Life's claim page both point policy owners to filing online at ColonialLife.com, where direct deposit can be selected. The online claim asks for the accident date and description, related bills with diagnosis information, an operative report if surgery was done, and an accident report for auto accidents.
Colonial Life's accident claim page tells policyholders who are unable to work to file a disability claim instead, using form 64387. Section 4 of the accident claim asks for dates unable to work, part-time hours and expected and actual return-to-work dates only if the patient is also covered under a disability policy.