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Colonial Life 49507: Pregnancy Claim Form

Colonial Life policyholders file this six-page claim after the birth to collect pregnancy benefits; the form says to use it only once the insured has given birth. The physician's Section 2 records the delivery, the hospital stay and the newborn's confinement. Pregnancy complications before delivery are claimed on Colonial Life's Disability Claim form instead.

Who completes it

The policy owner completes Section 1, including the last day worked and dates unable to work. The obstetrician or attending physician completes and signs Section 2, the physician statement.

Submitting and payment

How to submit it
The policyholder files online, with direct deposit available, or faxes or mails the completed form, including the physician's signed Section 2, to Colonial Life.
Who pays
Benefits are payable to the policyholder unless assigned in writing; for a Medicaid-covered claimant, most non-disability benefits are paid to Medicaid or to the medical provider.

Good to know

  • Section 2 asks for the delivery date, vaginal or C-section delivery, procedure code, diagnosis, anesthesia, date first treated and last menstrual period.
  • Record hospital admission and release dates with times and the newborn's hospital confinement dates; the hospital and any referring physician are also named.
  • The form asks whether the birth took place outside a hospital, at home, in a birth center, in a midwifery setting or elsewhere.
  • Revision 7-26. The physician block asks whether the practice accepts electronic authorizations, the standard HIPAA release and medical record requests by fax.

Get the official form

Download the current version from the source each time; forms change without notice.

Pregnancy Claim

Official pagePDF

How this list is checked

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.

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Frequently asked questions

What does the doctor complete on Colonial Life's pregnancy claim?

Section 2, the physician statement: date of delivery, type of delivery, procedure code, diagnosis, anesthesia, date first treated, last menstrual period, hospital admission and release dates and times, newborn confinement dates, and whether the birth was in a non-hospital setting. The physician signs and gives their specialty and Tax ID or SSN.

Can the Colonial Life pregnancy claim be filed before delivery?

No. The form states it is for use after the insured has given birth. A patient filing for pregnancy complications before delivery is directed to Colonial Life's Disability Claim form instead, which collects the physician's diagnosis and the dates the patient is unable to work.