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COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS If you are filing for disability and/or hospitalization, a claim form is required. To avoid delays, please answer all applicable qu
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Document Date: 2014-12-22 10:35:24


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Company

Consumer / COMBINED INSURANCE COMPANY / /

Facility

LABORATORY DATA AND ANY CLINICAL FINDINGS / /

/

MedicalCondition

MS / injury / sickness / /

MedicalTreatment

surgery / /

Organization

Health Records Department / Claims Department / /

/

Position

physician / Head Office / REFERRING PHYSICIAN / INJURIES SUSTAINED AM PM / /

RadioStation

INJURIES SUSTAINED AM / /

SocialTag