GROUP NUMBER
PLEASE CHECK CLAIM TYPE
q Occupational Illness
q Accident
q Accident Weekly Benefit
P.O. Box 4298 l Houston, Texas 77210-4298
PLEASE ENCLOSE THE ITEMIZED MEDICAL BILLS.
STATEMENT OF EMPLOYEE / PARTICIPANT
EMPLOYEE / PARTICIPANT INFORMATION
Name Social Security Number Date of Birth q Married
/ / q Single
- - q Divorced
Address (include zip)
Date of Accident Date of Report Time of Accident
/ / / / AM On the job? q Yes q No
PM
Name of Supervisor in charge at the time When was the accident reported to Supervisor?
Describe the accident and how it happened in detail. Attach additional paper if necessary.
Describe the injury and specify parts of body injured.
Does the injured employee want medical treatment? If no, have employee sign refusing medical attention.
Employee refuses medical attention and/or treatment
Employee Signature Supervisor Signature
Witness (3) to the accident:
Name Address Phone
(1)
(2)
(3)
Date of first medical treatment Treating physician and treating facility (name, address and phone number)
Has the employee ever been treated for this before? If yes, please explain.
6940.1 4/02 DOC-0767
IF THIRD PARTY INVOLVED SEE APPLICABLE SECTION ON “STATEMENT OF EMPLOYER / SPONSOR”
SIGNATURES
CERTIFICATION OF STATEMENT
I hereby certify that the above statements are correct and that the medical expenses submitted with this claim were incurred in the
manner indicated and for the patient named above.
WARNING:
Any person who knowingly, and with intent to defraud any insurance company or other person, files a statement of claim
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize any hospital, physician, or other person who has attended me or examined me to furnish to Philadelphia
American Life, or its authorized representative, any and all information with respect to any illness or injury, medical history,
consultation, prescriptions or treatment and copies of all hospital and medical records. Such release may include information which
may be considered a communicable and/or venereal disease, hepatitis, HIV related, AIDS, AIDS related disorders, mental/nervous
disorders, drug abuse and/or alcoholism. I also authorize Philadelphia American Life to disclose said information to the State
insurance regulator for an insurance regulatory purpose statutorily authorized by the State. A photostatic copy of this
authorization shall be considered as effective and valid as the original.
Employee’s / Participant’s Signature Date
ASSIGNMENT OF BENEFITS
I hereby authorize payment directly to the hospital and/or physician. I understand I am financially responsible for all charges not
covered by the Plan.
Employee’s / Participant’s Signature Date
My employer / sponsor is reimbursing my eligible expenses. I hereby authorize payment directly to my employer / sponsor.
Employee’s / Participant’s Signature Date
4. List the physicians most familiar with your health condition:
Name Address Zip Code Date Treated Phone #
5. Briefly describe the extent of education.
6. Briefly describe your job training and work experience.
6940.1 4/02 DOC-0767
STATEMENT OF EMPLOYER / SPONSOR
q Part-Time q Full-Time EFFECTIVE DATE OF
LAST DAY WORKED
DATE RELEASED TO ACTUAL DATE
Employee Employee COVERAGE RETURN TO WORK RETURNED TO WORK
q Part-Time q Full-Time / / / / / / / /
Participant Participant
q Hourly q Salaried Occupation
Employee Employee q Per Hour q Per Month
Salary $
q Hourly q Salaried q Per week q
Participant Participant
Employer / Sponsors Name By Date
Phone Number Tax Identification Number
1. Was a drug screen submitted? q Yes q No
2. If a drug screen was submitted please furnish the date and a copy of the results.
If a Third Party is involved, please complete the following questions:
1. Give the details of the accident. (Include a copy of the accident report)
2. Give the name and address of the responsible party.
3. Give the name and complete mailing address of the responsible party’s insurance company. (Include the POLICY NUMBER or CLAIM NUMBER)
4. Give the name and addresses of any attorneys representing all other parties involved.
Signature
Date
ASSIGNMENT OF BENEFITS
I hereby authorize my weekly benefit payment directly to my employer / sponsor.
Employee’s / Participant’s Signature Date
When having an employee/ participant complete the assignment of benefits, you are accepting the responsibility to withhold and report any applicable FICA taxes
for this individual.
COMMENTS & SUGGESTIONS:
Please have Physician complete his portion before returning.
6940.1 4/02 DOC-0767
Accident Weekly Benefits Only
P.O. Box 4298 l Houston, Texas 77210-4298
NOTE TO THE PHYSICIAN: Where space is limited, please furnish a narrative account or photocopies of medical statements.
ATTENDING PHYSICIAN’S STATEMENT
Name of
Employee / Participant: Name of Patient:
1. HISTORY
(a) When did symptoms first appear or accident happen? Mo. Day 20
(b) Date patient ceased work because of disability Mo. Day 20
(c) Has patient previously had same or similar condition? q Yes q No If “Yes” state when and describe:
(d) Is condition due to injury or sickness arising out of patient’s employment? q Yes q No q Unknown
(e) Name and addresses of other known treating physicians (this condition):
2. DIAGNOSIS (including any complications) / ICDA Code
(a) Date of most recent examination Mo. Day 20
(b) Diagnosis (including any complications)
(c) Subjective symptoms:
(d) Objective findings: ( including current X-rays, EKG’s, Laboratory Data and any clinical findings)
3. DATES OF TREATMENT
(a) Date of first visit for this diagnosis Mo. Day 20
(b) Date of most recent visit Mo. Day 20
(c) Frequency of visits/ treatment q Weekly q Monthly q Other (Specify)
4. NATURE OF TREATMENT (including Surgery and Medications prescribed, if any)
5. PROGRESS
(a) Has patient’s condition q Recovered? q Improved? q Unchanged? q Retrogressed?
(b) Is patient q Ambulatory? q House confined? q Bed confined? q Hospital confined
(c) Has patient been hospital confined? q Yes q No If “Yes”, give name and address of Hospital:
Confined from through
6. CARDIAC (if Applicable)
(a) Functional capacity q Class 1 (No limitation) q Class 2 (Slight limitation)
(American Heart Ass’n) q Class 3 (Marked limitation) q Class 4 (Complete limitation)
(b) Blood Pressure (last visit) /
SYSTOLIC DIASTOLIC
6940.1 4/02 DOC-0767
7. PHYSICAL IMPAIRMENT (*as defined in Federal Dictionary of Occupational Titles)
q Class 1 – No limitation of functional capacity; capable of heavy work* No restrictions. (0-10%)
q Class 2 – Medium manual activity* (15-30%)
q Class 3 – Slight limitation of functional capacity; capable of light work* (35-55%)
q Class 4 – Moderate limitation of functional capacity; capable of clerical/administrative (sedentary*) activity (60-70%)
q Class 5 – Severe limitation of functional capacity; incapable of minimal (sedentary*) activity (75-100%)
q Remarks:
8. MENTAL / NERVOUS IMPAIRMENT (if Applicable)
(a) Please define “stress” as it applies to this claimant.
(b) What stress and problems in interpersonal relations has claimant had in job?
q Class 1 – Patient is able to function under stress and engage in interpersonal relations (no limitations)
q Class 2 – Patient is able to function in most stress situations and engage in most interpersonal relations (slight limitations)
q Class 3 – Patient is able to engage in only limited stress situations and engage in only limited interpersonal relations
(moderate limitations)
q Class 4 – Patient is unable to engage in stress situations or engage in interpersonal relations (marked limitations)
q Class 5 – Patient has significant loss of psychological, physiological, personal and social adjustment (severe limitations)
q Remarks:
Do you believe the patient is competent to endorse checks and direct the use of proceeds thereof? q Yes q No
9. PROGNOSIS
PATIENT’S OCCUPATION ANY OTHER WORK
(a) Is patient now totally disabled? q Yes q No q Yes q No
(b) What duties of patient’s job is he/she incapable of performing?
Do you expect a fundamental or mark
change in the future? q Yes q No q Yes q No
(1) If yes, when do you feel q 1 Mo. q 3-6 Mos q 1 Mo. q 3-6 Mos
/ / / /
patient will recover sufficiently q 1-3 Mos q Never q 1-3 Mos q Never
Mo. Day Yr. Mo. Day Yr.
(2) If no, please explain
(c) Date of next scheduled office visit?
10. REHABILITATION
(a) Is patient a suitable candidate for further rehabilitation services? ( i.e. cardiopulmonary program, speech therapy, etc.)
q Yes q No
(b) Do you feel present job can be modified to allow for handling with impairment? q Yes q No
PATIENT’S OCCUPATION ANY OTHER WORK
(c) When could trial employment / / q Full-time / / q Full-time
commence? Mo. Day Yr. q Part-time Mo. Day Yr. q Part-time
(d) Would vocational counseling and/or retraining be recommended? q Yes q No
11. REMARKS
Name (Attending Physician) Please Print Degree Telephone
Street Address City or Town State or Province Zip Code
Signature
6940.1 4/02 Date DOC-0767