TO BE COMPLETED BY THE CLAIMANT PLEASE TYPE OR PRINT BE SURE TO ANSWER ALL QUESTIONS - FAILURE TO DO SO MAY DELAY YOUR CLAIM. USE SEPARATE PIECE OF PAPER TO COMPLETE ANSWERS IF NECESSARY DATE OF ACCIDENT OR BEGINNING DATE FIRST UNABLE TO WORK DATE YOU PLAN TO RETURN TO WORK LIST STATES IN WHICH YOU MAY BE LIABLE FOR FILING TAX RETURNS OF SICKNESS DESCRIBE IN YOUR OWN WORDS WHAT IS WRONG WITH YOU (IF ACCIDENT, DESCRIBE HAVE YOU HAD THE SAME OR SIMILAR CONDITION IN THE PAST? IF SO, PLEASE DESCRIBE IN DETAIL. CIRCUMSTANCES AND ADVISE WHETHER IT OCCURRED AT WORK). PLEASE LIST ANY HOSPITALS, CLINICS OR PHYSICIANS THAT TREATED YOU FOR YOUR ILLNESS OR INJURY. NAME COMPLETE ADDRESS TREATMENT PERIOD PLEASE DESCRIBE YOUR JOB DUTIES IN DETAIL. WHAT PERCENT OF YOUR JOB REQUIRES PHYSICAL LABOR? PLEASE LIST ALL BENEFITS YOU ARE RECEIVING OR ELIGIBLE TO RECEIVE UNDER ANY OTHER GROUP INSURANCE, GOVERNMENT PLAN OR AUTOMOBILE MANDATORY NO-FAULT COVERAGE. BENEFIT GROSS WEEKLY AMOUNT DATE BEGAN PAID THRU DATE PLEASE PROVIDE THE NAME OF YOUR MEDICAL INSURANCE CARRIER THIS IS TO CERTIFY THAT THE FACTS AS INDICATED ABOVE ARE TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE OF AUTHORIZED REPRESENTATIVE DATE SIGNED The issuance of this form is not an admission of the existence of any insurance nor does it recognize the validity of any claim and is without prejudice to the company’s legal rights. TO BE COMPLETED BY ATTENDING PHYSICIAN DIAGNOSIS AND CONCURRENT CONDITIONS, INCLUDING ICD OR DSM CODE. IS CONDITION DUE TO PREGNANCY? YES NO IF "YES", PLEASE PROVIDE THE FOLLOWING INFORMATION IF APPLICABLE. APPROXIMATE DATE PREGNANCY COMMENCED ESTIMATED DATE OF CONFINEMENT DATE OF DELIVERY TYPE OF DELIVERY COMPLICATIONS IS CONDITION DUE TO INJURY OR SICKNESS ARISING OUT OF DATE SYMPTOMS FIRST APPEARED OR ACCIDENT HAPPENED. DATE PATIENT FIRST CONSULTED YOU FOR THIS CONDITION. PATIENT’S EMPLOYMENT? YES NO DATES OF SERVICE - INCLUDE DATE OF NEXT APPOINTMENT (IF PREVIOUS FORM SUBMITTED TO THIS CARRIER, YOU NEED SHOW ONLY DATES SINCE LAST REPORT). HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION? YES NO IF "YES", WHEN AND DESCRIBE PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? YES NO HAS PATIENT BEEN HOSPITAL CONFINED? YES NO IF "YES", CONFINED FROM THRU NAME AND ADDRESS OF HOSPITAL NATURE OF SURGICAL PROCEDURE, IF ANY INPATIENT OUTPATIENT DATE PERFORMED PATIENT WAS CONTINUOUSLY TOTALLY DISABLED - (UNABLE TO WORK) IF STILL DISABLED, DATE PATIENT SHOULD BE ABLE TO RETURN TO WORK. From: Thru: REMARKS: WE ARE INTERESTED IN ANY INFORMATION THAT WOULD BE HELPFUL TO YOUR PATIENT FOR EVALUATION OF THIS CLAIM. DATE PHYSICIAN’S NAME (PRINT) SIGNATURE DEGREE SOCIAL SECURITY NUMBER TAX IDENTIFICATION NUMBER STREET ADDRESS CITY OR TOWN STATE OR PROVINCE ZIP CODE TELEPHONE Page 2 of 4 500385 Rev. 10/2022