Family Heritage Insurance Claim Form Instructions & Details

Submit the completed claim form along with any required documents to Family Heritage Life Insurance Company of America. You can mail the form to P.O. Box 470608, Cleveland, OH 44147 or submit it via fax to (440) 922-5151. For online submissions, visit the official Family Heritage website and follow the instructions for uploading your completed form. Ensure all sections are filled out accurately and all necessary documentation is attached before submission for efficient processing. My advice: double-check all fields for completeness and accuracy to avoid delays.

Ensure your claim is submitted promptly to avoid delays. Important dates include the date of the accident, hospital admission, treatment start date, and any relevant deadlines for submitting supporting documents. Keeping track of these dates will ensure your claim is processed efficiently.

The purpose of this form is to provide a streamlined process for filing claims with Family Heritage Life Insurance Company of America. The form is divided into sections for accidental injury, accidental death, and intensive care unit claims, ensuring that all relevant information is collected for accurate processing. By following the instructions and providing the necessary documentation, claimants can help expedite the evaluation and approval of their claims. Completing this form accurately is crucial for ensuring timely processing and avoiding delays. It is important to answer all required questions truthfully, gather the necessary supporting documents, and complete the physician's statement if applicable. Providing false or misleading information can result in severe penalties, so claimants should take care to fill out the form thoroughly and honestly. This form also includes an authorization for the release of medical information, allowing the insurance company to access relevant medical records for claim evaluation. By signing this authorization, claimants enable the insurer to review their medical history and make informed decisions about their claim. Ensuring that all sections of the form are completed and signed will help facilitate a smooth and efficient claims process.

• 1. Policyowner's Name: The name of the person who owns the insurance policy.
• 2. Policy #: The unique policy number assigned to the insurance policy.
• 3. Claimant's Information: Information about the person filing the claim, including name, address, phone number, and date of birth.
• 4. Social Security No: The claimant's Social Security number for identification purposes.
• 5. Occupation: The claimant's occupation at the time of the claim.
• 6. Relationship to Policyowner: The claimant's relationship to the policyowner (self, spouse, son, daughter, or other).
• 7. Date of illness/accident: The date when the illness or accident occurred.
• 8. Date first consulted physician: The date when the claimant first consulted a physician for the illness or injury.
• 9. Place of illness/injury: The location where the illness or injury occurred.
• 10. Describe how illness/injury occurred: A brief description of how the illness or injury occurred.
• 11. Nature of illness/injury: A description of the nature of the illness or injury.
• 12. List all treating physicians: The names and phone numbers of all physicians who treated the claimant.
• 13. If hospitalized, when: The dates when the claimant was hospitalized, including the name and phone number of the hospital.
• 14. Authorization: An authorization section that must be signed by the claimant, patient, parent (if the patient is a child), or executor, allowing the insurance company to access medical records for claim evaluation.
• 15. Supplemental Physician's Statement: A section to be completed by the treating physician, including diagnosis, diagnosis code(s), accident details, treatment history, and any other relevant information.

Failing to submit this form will result in delays or denial of your insurance claim. It is important to complete and submit the form promptly to avoid any interruptions in the claims process.

• Claim Denial: Your claim may be denied if the required form is not submitted on time.
• Delayed Processing: Failure to submit the form can lead to delays in processing your claim and receiving benefits.
• Incomplete Information: Not providing the necessary documentation and information may result in the insurance company being unable to evaluate your claim.

• 1. Accidental Injury Claim: Submit this form along with itemized hospital and medical bills, x-ray reports, and police reports if applicable.
• 2. Accidental Death Claim: Submit this form completed by the spouse/executor and physician along with an original, certified copy of the death certificate, police reports, and autopsy reports if applicable.
• 3. Intensive Care Claim: Submit this form for each hospital admission along with a copy of the itemized hospital bill listing the Intensive Care charges and an ambulance bill if applicable.
• 4. Supplemental Physician's Statement: Have the treating physician complete the required sections about the patient's diagnosis, treatment, and condition.
• 5. Authorization for Medical Records: Authorize the insurance company to access the claimant's medical history and records by signing the provided authorization form.