FORMS

Accident Medical Expense (AME)

When filing a claim under your Accident Medical Expense policy, please be sure to fully answer the questions on the claimant's statement, including the names, addresses and telephone number of your physicians. Attach a Medical Insurance Summary of Benefits or a bill from your provider of service that itemizes your out-of-pocket expenses and includes the provider's name and address, name of the patient, dates of treatment, diagnosis and charges for services.

Our claims department will contact you if a HIPAA authorization or prescription history authorization is needed for review of your claim.

AME Claimant's Statement


Bank Draft Authorization

Changes to your bank information must be submitted to us in writing. Please fully complete and sign the Bank Draft Authorization Form and submit it to us via email to billing@dearbornnational.net or via fax to 303-267-7599 or via US Mail to; Colorado Bankers Life Insurance Company, 2327 Englert Drive, Durham, NC 27713.

Bank Draft Authorization Form


Critical Illness Insurance (Critical Condition and Living Benefit)

The following forms apply to the Critical Illness Insurance policy. When you have a claim to file, please complete the claimant's statement and answer all of the questions fully. Have your physician complete and sign the attending physician's statement that is appropriate to your condition. There are specific forms to use if you have had a stroke or heart attack (myocardial infarction).

Our claims department will contact you if a HIPAA authorization or prescription history authorization is needed for review of your claim.

Critical Illness Insurance Claimant's Statement
Attending Physician Statement for Critical Illness Insurance
Attending Physician Statement for Heart Attack (Myocardial Infarction)
Attending Physician Statement for Stroke


Lost Policy

This form is to request a duplicate policy. A duplicate policy fee of $20.00 is required if the policy has been in effect for a year or more. An Explanation of Benefits will be sent if no fee is received.

The form can be submitted via email to customerservice@dearbornnational.net, via fax to 303-220-8056 and lost policy fees (if applicable) can be sent via US Mail to Colorado Bankers Life Insurance Company 2327 Englert Drive, Durham, NC 27713.

Lost Policy Form


Monthly Disability Income (MDI)

To be eligible to file a Disability Income claim, you must be totally disabled and unable to work for at least 30 continuous days. The policy premiums must be paid to keep your policy active, and the claim needs to be filed while you are disabled. Please be sure to fully answer the questions on the claimant's statement and have your physician complete and sign the Attending Physician's statement.

Our claims department will contact you if a HIPAA authorization or prescription history authorization is needed for review of your claim.

Disability Income Claimant's Statement
Attending Physician's Statement


Paycheck Protection Plus (PPP and Accident Disability Insurance)

The following policy definition must be met to file a claim for total disability benefits on your accident only policy: During the first two years of a loss, means the inability to perform all the substantial and material duties of your regular occupation. After the first two years of a loss, it means the inability to perform the material and substantial duties of any occupation for which qualified by education, training or experience.

In order to process your claim we need a fully completed and signed claimant's statement and an attending physician's statement that has been completed and signed by your physician. Please attach the itemized medical bills that include the name and address of the medical facility, the name of the patient, the dates of treatment, the diagnosis and the charges for services.

Our claims department will contact you if a HIPAA authorization or prescription history authorization is needed for review of your claim.

Paycheck Protection Plus Claimant's Statement and Attending Physician's Statement


Social Security Disability for Critical Illness Insurance (SSD)

When filing a claim under your Social Security Disability for Critical Illness Insurance (Critical Condition Accelerated) policy, please be sure to fully answer the questions on the claimant's statement. If you are a resident of a community property state then your marital status and spouse's signature (if applicable) are required.

Have your physician complete and sign the attending physician's statement and include the Social Security Disability award notice if you have been approved for Social Security Disability benefits.

Our claims department will contact you if a HIPAA authorization or prescription history authorization is needed for review of your claim.

Social Security Disability Claimant's Statement
Attending Physician's Statement for Social Security Disability Insurance


Waiver of Premium (WP)

To be eligible to file a Waiver of Premium claim you must be totally and permanently disabled and completely unable to engage in any gainful occupation for at least six continuous months, and the premiums need to be paid to keep your policy in force. Additionally, the claim needs to be filed within one year after the onset of your disability and while you are still disabled.

Please be sure to fully complete the questions on the claimant's statement and have your physician complete and sign the attending physician's statement.

Our claims department will contact you if a HIPAA authorization or prescription history authorization is needed for review of your claim.

Disability Income Claimant's Statement
Attending Physician's Statement

For questions about your policy or about how to complete these forms, please go to our FAQs or Contact Us.