• Doctor’s Medical Diagnosis
• Dates of Medical Treatment (copies of medical and/or hospital bills)
• Description of Accident or Health Condition, including the date the accident occurred and a description of the accident
• Signed Authorization (by you) at the bottom of claim form

The following additional information may be required depending on the claim submitted.
Cancer Claims – Pathology or laboratory report, medical bills (all charges itemized) and procedure codes

Health Screening or Wellness Claims – date of service, type of test performed, charges, and provider’s name, address and phone number

Disability Claims – dates of treatment, dates of disability from both doctor and employer, treating doctor’s estimated return to work date

Hospitalization Claims – Admission and discharge dates, and discharge summary

Critical Illness Claims – A completed doctor’s statement, the date of diagnosis and related medical history.

• Premiums are payroll-deducted, contact your payroll department to restart payroll deductions.
• You are paying by bank draft, check, or money order; send a check for one month’s premium to Colonial.

If your policy has been out of force for more than 30 days, follow the above guidelines and also complete and submit an Application for Reinstatement form to Colonial. These forms are available from your employer, Colonial sales representative, or by calling the Colonial Service Center (1-800-325-4368).

• requesting a copy from his or her employer or the entity to which the group policy is issued;
• visiting www.unumprovident.com/privacy or www.coloniallife.com; or
• writing to: Privacy Officer, Unum Group, 2211 Congress Street, M347, Portland, Maine 04122.