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Combined insurance claim forms printable 2025

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The document is a Combined Insurance Claim Form that requires the claimant to provide personal information, details about the accident or sickness, and medical history for processing an insurance claim. It includes sections for both the claimant and their medical practitioner to complete, outlining necessary information for assessing claims related to accidents or illnesses. The form also contains instructions on how to fill it out, privacy consent details, and procedures for complaints and dispute resolution.

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Click ‘Get Form’ to open the combined insurance claim form in the editor.
Begin by filling out Section 1, ensuring you print using BLOCK LETTERS. Enter your Account Number, Full Name, and Postal Address accurately.
Provide your Employer's Name, Occupation, Date of Birth, Height, Weight, and Contact Number. If claiming under a Family Policy, indicate 'Yes' or 'No'.
For accident claims, specify the date and time of the accident and describe how it occurred. Indicate if emergency ambulance transport was required.
For sickness claims, detail the nature of your sickness and when symptoms first appeared. Include any previous occurrences of the same condition.
Complete hospitalization details if applicable. Provide dates for inpatient treatment and any relevant medical practitioner information.
Review all entries for accuracy before signing the declaration at the end of Section 1.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I make a claim on combined insurance?

To file Combined Insurance claims, print the claim form instructions, then simply click and print out the appropriate form from the available list below. Complete the form; specific sections must be completed by your employer and doctor, and mail or fax it to the appropriate address or fax number.

What is a claim form?

A claim form is a formal written request to the government, an insurance company, or another organization for money that you think you are entitled to according to their rules.

What are the two types of claim forms?

The two most common claim forms are the CMS-1500 and the UB-04. These two forms look and operate similarly, but they are not interchangeable. The UB-04 is based on the CMS-1500, but is actually a variation on itits also known as the CMS-1450 form.

What are the two forms of claims?

Three types of claims are as follows: fact, value, and policy. Claims of fact attempt to establish that something is or is not the case. Claims of value attempt to establish the overall worth, merit, or importance of something. Claims of policy attempt to establish, reinforce, or change a course of action.

How long do I have to file a claim with combined insurance?

How long from the date of the service do I have to file a claim? In order to take care of your claim as soon as possible, we ask that you give us written notice of a claim within 30 days after a covered loss starts, or as soon as is reasonably possible.

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What is the difference between CMS-1500 and UB04 claim form?

When a physician has a private practice but performs services at an institutional facility such as a hospital or outpatient facility, the CMS-1500 form would be used to bill for their services. The UB-04 (CMS-1450) form is the claim form for institutional facilities such as hospitals or outpatient facilities.