Unum uses this claim form for supplemental health accident insurance, which pays a set amount based on the injury and the treatment required, as determined by the physician, and the coverage elected. On the one-page Attending Physician Statement the physician confirms the accidental injury and its date and verifies the treatment, from office and emergency visits to hospital stays, surgery and therapy referrals.
The physician or treating provider primarily responsible for the patient's care completes the Attending Physician Statement on page 8. The employee completes the Employee Statement on pages 4 to 6 and signs the Patient Authorization on the last page.
Enter the employee's last name, first name, middle initial and date of birth, then the patient's on the separate line below. Unum's instructions ask for complete and legible answers so the claim can be processed as quickly as possible, and the statement asks you to print in the fields provided.
Answer whether the condition is the result of an accidental injury and, if so, give the date of the accident. Then answer whether the condition is the result of the patient's employment: yes, no or unknown. These two answers frame the rest of the statement, which asks you to verify treatment for the accident listed.
Print the primary diagnosis ICD code and description and any secondary diagnosis code and description, then the first and last office visit dates. Answer whether the patient was hospitalized because of the accident and, if so, give the admission and discharge dates and the hospital's name, city and state.
Answer whether surgery was performed and give the date and a description of the surgery or procedure. Say whether the patient was referred to physical, speech, occupational, acupuncture or alternative therapy, and name the therapy facility or prescribed frequency. Answer whether the patient was referred to behavioral health therapy and whether they were treated in the emergency room for the injury, with the date.
Answer whether you advised the patient to stop working and, if so, as of what date, and whether you have advised the patient to return to work, with that date. Leave neither question blank: both have yes and no boxes, and each yes needs its date.
The fraud notice states that knowingly filing false or misleading information is subject to criminal and civil penalties, including on the Attending Physician portion. Print your name, medical specialty, degree, address, telephone and fax numbers and Tax ID number, answer whether you are related to the patient, and sign and date to confirm the statements are true and complete.
Download the current version from the source each time; forms change without notice.
Accident Claim Form
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Sources for this guide
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Page 8, the Attending Physician Statement. The physician or treating provider primarily responsible for the patient's care confirms whether the condition resulted from an accidental injury, gives diagnosis codes and visit dates, and verifies hospital stays, surgery, therapy referrals and emergency room treatment. The patient's authorization to release information is on the last page.
Not Unum. The form's instructions state that Unum is not responsible for expenses associated with completing the Attending Physician Statement. The accident benefit itself is a set amount paid directly to the insured, based on the injury, the treatment required and the coverage elected.
Yes. Unum says the fastest way to file is its web portal or app, where a claim can be saved and finished later and medical records can be photographed and uploaded from a phone. The paper form can also be faxed or mailed following its instructions, and accident claims can be filed by phone.