Fill out the top section and give details about your accident or illness. Your supervisor needs to fill out the middle section, and your doctor will need to fill out the bottom section.
For questions, please refer to our Frequently Asked Questions page.
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You’ll need to write in the details of your accident, and have your supervisor give details about your time off work. Then your doctor will need to write in your diagnosis and the dates you will be off work. You can fax it to the claims department at the number listed on the claim form, or call the claims department and they will help you file it.
If you want to make a claim for your critical illness benefit, fill out the Combined Insurance claim form. You will need to provide them with details about your illness. Your doctor will need to provide information about your treatment as well. You can call Combined’s claims department at the number listed on the form for help with filing your claim.
If you, the beneficiary, need to make a claim on the member’s plan, use Combined’s Beneficiary Statement for Life Insurance form. If you, the member, need to make a claim for your Long Term Care benefit, use the Combined Insurance claim form.
Your Dental provider should file a claim for you. However, if you go to a provider that does not file claims for you, use our Dental claim form.
If you choose an out-of-network vision provider, use the VSP Member Reimbursement Form to make a claim under your plan. Use this form only if you choose a non-network provider.