Colonial Life critical illness coverage pays a lump-sum benefit when a covered condition such as cancer, heart attack, stroke, coma or major organ failure is diagnosed, and patients file for it on this 11-page claim. Colonial Life needs supporting documents from the provider showing the diagnosis, the records behind it and the date of diagnosis. The physician statement ties each condition to the specific evidence the policy requires.
The policy owner completes Section 1 and signs the certification. The treating physician completes Section 2-a, selecting the condition and giving the evidence for it, and signs; Section 2-b and the employer's Section 3 are completed only when the patient is also filing for disability.
The policy owner gives the claimant's and policy owner's details, any hospital admissions with dates and times, and the treating, primary and referring physicians. They check the condition being claimed from the policy list, give the type of illness and the date first treated, and answer whether they have a Colonial Life disability policy, with the last day worked, dates unable to work and employer contacts.
The policy owner checks any rider benefit claimed: Heart Benefits (such as valve repair, stents or pacemaker placement), Infectious Diseases (such as sepsis, MRSA or Lyme disease) or Progressive Diseases (such as ALS, dementia, MS or Parkinson's), or a covered dependent child's condition. The claimant and policy owner then sign and certify. A beneficiary section, with a death certificate, is used if the insured has died.
Check the condition and give the evidence beside it. Benign brain tumor: date of the biopsy or neuroradiological report. Blindness: irreversible loss in both eyes lasting at least 180 days. CABG: dates recommended and performed. Invasive cancer: malignant cells confirmed, date diagnosed, pathology report. Carcinoma in situ: stage 0, date diagnosed. Coma: 7 or more consecutive days. End-stage renal failure: date dialysis began.
Heart attack needs records of typical chest pain, new EKG changes, rising cardiac markers or confirmatory imaging. Loss of hearing, sight or speech needs the date a physician certified it, with visual acuity and fields for sight. Organ failure needs the UNOS listing date and any transplant. Occupational HIV or hepatitis needs a positive test 90 to 180 days after the accident. Stroke needs any deficits past 30 days and the neuroimaging date.
For a heart rider procedure, give the date and CPT code; it must be due to acute coronary syndrome, atherosclerosis, coronary artery disease, cardiomyopathy or valvular heart disease. For an infectious disease, give the diagnosis date, ICD-10 code and hospital confinement dates. For a progressive disease, give the diagnosis date, ICD-10 code and the date the patient became unable to perform two or more listed activities of daily living.
Answer whether the patient was treated for the same or a similar condition before, and whether they were hospitalized for this condition, with admission and discharge dates and the hospital's contact details. Add the diagnosis, first date of treatment and referring physician. The physician signs and dates, then gives the physician or group name, tax ID or SSN, specialty, contact numbers and address.
Complete only when the claim includes disability. State whether restrictions or limitations are permanent, listing what the patient cannot do and should not do. Give the dates unable to work full time, the expected return-to-work date, any part-time dates and hours, the actual return-to-work date, house confinement dates and the activities of daily living the patient cannot perform. This section has its own physician signature.
Used only for a disability claim. The employer gives the employee's title, hire date, scheduled hours, date last worked, dates unable to work, when sick leave was exhausted, FMLA approval dates, workers' compensation details and pay, whether light or partial duty is allowed, return-to-work dates and the job's physical duties, and an authorized person signs.
Download the current version from the source each time; forms change without notice.
Critical Illness 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
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Section 2-a, the physician statement. The physician selects the covered condition or rider benefit, gives the dates and findings the form asks for, such as the date diagnosed or the date of confirmatory imaging, and attaches the supporting report. The physician then lists prior treatment and hospitalizations and signs. Section 2-b is added only for a disability claim.
Every claim needs supporting documents from the provider showing the diagnosis, records that support it, such as pathology reports, surgical notes, lab results or clinical records, and the date of diagnosis. Section 2-a then names condition-specific proof, for example the biopsy or neuroradiology report for a benign brain tumor or the date dialysis began for end-stage renal failure.
Not by itself. Colonial Life says a patient also filing for disability insurance benefits needs to submit a disability claim form as well. Within form 65017, Section 2-b is a second physician statement for disability, covering restrictions, dates unable to work and return to work, and the employer completes Section 3.
Some policies pay a benefit for a dependent child diagnosed with cerebral palsy, cleft lip or palate, cystic fibrosis, Down syndrome or spina bifida. When filing for one of these, the dependent's name goes in the claimant name field in every section, and the claim needs a completed physician's statement or other information that confirms the diagnosis.