To be completed by the insured
Policy Holder Name
Date of Birth
Policy Number
Address
(Street)
(City)
(State)
(Zip Code)
Phone
Type of benefit(s) for which the claim is being made: Daily Benefit (Facility Care): (Complete parts A & B on next page) Nursing Facility Assisted Living Facility Hospice Care Bed Reservation
“Fast-50” Benefit (Facility Care or Home Care Benefit) (Complete parts A, B & C on the next page) (Note: If you elect to receive the Fast-50 Benefit, we will pay fifty percent (50%) of your per day Facility Care, or Home Health Care Benefit amount shown on the policy schedule. The elimination period for the Facility Care Benefit and Home Health Care Benefits, if any, is waived if you elect to receive this benefit. If you are eligible for the Facility Care Benefit or Home Home Health Care and elect the Fast-50, we will pay the Fast-50 Benefit for each day you meet the coverage requirements. If you switch from the Fast-50 to the Facility Care or Home Health Care benefits, you still must satisfy the elimination period.) Home Health Rider: (Complete parts A, B & C on the next page) Nursing Care (RN/LPN/LVN) Chemotherapy Specialist Respiratory Therapy Speech Pathology Physical Therapy Other Hospital Indemnity Rider: (Complete part A on next page) Date Range of Hospitalization From:___________________ To:_ _____________________ Reason for Hospitalization:_ ________________________________________________________________________ Date symptoms first appeared:_ ________________ Date of first visit with physician?_____________________________ Date of actual/definitive diagnosis:________________________ Enterostomal Therapy Home Health Care Aide Medical Social Services Occupational Therapy Have you ever had this illness/condition before? □ Yes □ No If yes, date of previous diagnosis?___________________ If yes, what is the name, address, and telephone number of physician that previously provided the diagnosis?___________ __________________________________________________________________________________________________ If hospitalized for this illness/condition, what’s the name and address of hospital/medical center?_ __________________ __________________________________________________________________________________________________ Are you now, or have you received home health care services before? If yes, when:________________________________ What condition were/are you receiving care for?_ __________________________________________________________ Have you ever been diagnosed with a cognitive illness? What diagnosis: _____________________ When:_ _____________ (A cognitive illness is classified as the inability to think, understand, learn, and remember on one’s own.) Your Primary Care (family doctor) name, address, and telephone number:________________________________________ __________________________________________________________________________________________________ Were there any OTHER PHYSICIANS seen during the last two (2) years? (if more space is needed, please attach separate sheet) If so, please provide their names, addresses and phone numbers: Physician Name_ ______________________________________ Type of Doctor__________________________________ Address and Phone Number____________________________________________________________________________ Physician Name_ ______________________________________ Type of Doctor__________________________________ Address and Phone Number____________________________________________________________________________
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STC-CF 0624
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