Holders of a Guardian individual accident policy use this claim form after an accident causes dismemberment, coma, paralysis or a loss such as sight, speech or hearing. The attending physician's section on page 2 confirms the diagnosis and date of the amputation or loss, describes the injuries, checks the specific loss from Guardian's list, adds vision findings for eye losses, and notes any disease that may have contributed.
The primary subscriber, or a covered member, completes page 1 with accident details and signs the authorization. The attending physician completes and signs the Attending Physician's Section on page 2.
Download the current version from the source each time; forms change without notice.
Accidental Dismemberment, Coma & Paralysis Claim Form
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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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The physician section asks for medical treatment records, progress notes, results from all tests performed and the operative report to support the diagnosis. The subscriber's part describes the accident in order of events and names all attending physicians.
The last question on the physician section asks, if the injuries were not due to an accident, for details of any condition or disease that in the physician's opinion may have been a contributory cause. Guardian uses this to judge whether the loss falls under the accident policy.