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DISABILITY CLAIM FORM The Benefits Center P.O. Box[removed], Columbia, SC[removed]Pacific Time Zone Toll-free: [removed]  Fax: [removed]All Other Time Zones Toll-free: [removed]  Fax: [removed]
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Document Date: 2014-01-10 10:17:04

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File Size: 1,10 MB

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City

New York / /

Company

Accident Insurance Company / Change Direct Deposit Account Bank / Savings Bank Routing / Phone Number Employer Address City State Prior LTD / Unum Life Insurance Company of America / Carrier Name Zip - Prior LTD / Carrier Employee Effective Date Prior LTD / Unum Group / /

Country

Puerto Rico / Columbia / /

Currency

USD / /

Facility

Hospital Address Date / /

/

IndustryTerm

bank account / insurance / insurance application / insurance benefits / insurance proceeds / fraudulent insurance act / insurance fraud / Alabama law / /

Organization

Colorado Division of Insurance / Department of Regulatory Agencies / Attending School / Contact Center / /

Person

Designee / Guardian / /

/

Position

Attorney / claims specialist / physician / Prescription Name Dosage/Frequency Prescribing Physician / Representative / attending physician / /

Product

Direct Deposit Customer Service / /

ProvinceOrState

Texas / Kentucky / New Jersey / West Virginia / Ohio / Minnesota / Virginia / Alabama / Alaska / Maine / Maryland / Indiana / Louisiana / New York / Washington / Tennessee / New Mexico / District of Columbia / Pennsylvania / Rhode Island / South Carolina / Oklahoma / Columbia Residents For / Delaware / Florida / California / Arizona / Idaho / Colorado / Arkansas / New Hampshire / /

Region

West Virginia / /

URL

unum.com / /

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