Get Assurity Insuranse Continued Disability Claim Form

Filling out the Assurity Insuranse Continued Disability Claim Form online can be a straightforward process when guided step-by-step. This guide aims to provide you with clear instructions for each section of the form to help you complete your claim efficiently and accurately.

Follow the steps to fill out your claim form online effectively.

1. Click the ‘Get Form’ button to access the Assurity Insuranse Continued Disability Claim Form, opening it in your preferred online document editor.
2. Begin by filling out the section for patient and policyholder information. This includes the patient's name, birthdate, and address. Remember to check the box if you have a new address. Also, provide the required relationship details and contact numbers.
3. In section B, provide the physician's statement. Ensure that your physician's name, diagnosis code, and contact details are complete. It's important to include the dates of service and any diagnosis descriptions requested.
4. For section C, your physician will need to fill out the disability statement. Indicate the first date of disability, last date of treatment, and whether the patient is ambulatory, bed-confined, or hospitalized.
5. In section D, if applicable, your employer will complete the employer's disability statement. This includes details about your work status, salary, and reasons for absence.
6. Review all sections carefully to ensure that all necessary fields are filled accurately. Sign the claim form at the bottom of page two.
7. After completing the form, save your changes. You can then download, print, or share the completed form as needed.

Start completing your Assurity Insuranse Continued Disability Claim Form online today to streamline your claim process.