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Injury and Illness Proof of Loss Form

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INJURY AND ILLNESS PROOF OF LOSS FORM

Seven Corners, Inc.

303 Congressional Blvd.

Carmel, IN 46032

800-335-0477 or 317-575-2656 Fax: 317-575-2256

To be considered, proof of loss form and receipts for expenses must be submitted within 90 days of the date of service!!!

Instructions:

1. This form must be completed by the Insured in full to be considered for Medical Expense Payment.

2. Fully itemized bills including Claimant’s Name, Nature of Illness/Injury, must be included with this proof of loss form.

3. Description and Charge for each service provided.

4. This form must be signed and dated in all applicable sections. In most cases, two signatures are required.

5. This form and all attached bills must be submitted to the address indicated above.

6. If you would prefer reimbursement in Africa, complete Page 4. Required for any reimbursement in Africa.

The furnishing of this form, or its receipt by the Company, must not be construed as an admission of any liability on the Company, nor a waiver of any of the conditions of the insurance contract. Any person who knowingly and/or with intent to injure, defraud, or deceive an insurance company or other person files a statement of claim containing false, incomplete or misleading information, may be guilty of insurance fraud and subject to criminal and substantial civil penalties.

coverage information

Insurance Carrier:

Name of Group / Plan:

Policy / Certificate Number:

Coverage Effective Date (month/day/year)

Coverage Termination Date (month/day/year)

insured information / claimant information

Name of Insured (last, first, middle initial, suffix):

Name of Claimant (last, first, middle initial, suffix):

Date of Birth (month/day/year)

Sex:

Date of Birth (month/day/year)

Sex:

current address / permanent address

Current Residence Address (address, city, state, postal code, country):

Permanent Address In Home Country (address, city, state, postal code, country):

Daytime Phone Number (area and / or country code)

Email Address:

If Applicable, Date of Arrival in U.S. (month/day/year) or N/A

If Applicable, Date scheduled to return to Home Country:

If Applicable, Date of Arrival in U.S. (month/day/year) or N/A

medical information

If Injury, provide details, i.e., how when and where injury occurred:

INJURY AND ILLNESS PROOF OF LOSS FORM

Name of Insured (last, first, middle initial, suffix):

Policy / Certificate Number:

If Illness, advise when and where symptoms first occurred and nature of illness:

Name and address of Consulting or Treating Physicians:

Have you ever been treated for this Illness before?

If Yes, when?

Provide Name and Address of your Primary Care Physician in your Home Country:

Indicate other Employer / Private / Government Medical Insurance coverage, include name, address, policy number and certificate number of Insurer:

Please advise names of any prescription medications you are presently taking:

Authorization and certification:

FRAUD NOTICES

General: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Arkansas, Louisiana, Maryland, West Virginia: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

California: For your protection California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.

Connecticut: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony.

Delaware, Idaho, Indiana: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

District of Columbia: Warning: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Hawaii: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.

Michigan, North Dakota, South Dakota: Any person who knowingly and with intent to defraud any insurance company or another person files a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and subjects the person to criminal and civil penalties.

Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Nevada: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under state or federal law, or both, and may be subject to civil penalties.

New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud as provided in section 638:20.

New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

New Mexico: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Oregon: Any person who makes an intentional misstatement that is material to the risk may be found guilty of insurance fraud by a court of law.

Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Claim Correspondence/Payment Instructions

primary information

Insured:

ID #:

Patient:

Email address:

correspondence information

Correspondence to US:

Correspondence to Outside the US:

Phone # in the US:

Phone # Outside of the US:

Address in the US (address, city, state, postal code):

Address Outside the US (address, city, state, postal code, country):

payment information

Payments to be sent to:

Address in US:

Address outside the US

Bank account in the US*: (If yes provide Banking Information in section below)

bank information

Bank’s name:

Bank’s Address (address, city, state, postal code, country)

Bank’s Phone #

Bank’s Account:

Type of account:

Name on Account (exactly as it appears on your bank statements):

IBAN Number and/or Swift Code (required for wire transfers):

Bank currency for this account:

Bank routing/sort code:

*Checks cannot be sent to Banks outside the United States    **Wire transfer for Banks outside the United States only (Greater than $50.00 USD)

Disclaimer:

I hereby authorize and request Seven Corners to mail any correspondence and/or payments to the above listed address. I further agree to release Seven Corners of any and all liability in the event of lost or stolen correspondence/payments.

Signature of Insured

Date

Optional for Insured’s Convenience

I further agree to allow Seven Corners to send copies of explanation of benefit forms, copies of claim correspondence, and other confidential medical information about my claim or the claims of other insureds on my policy to the following email address:

Date

Signature of Insured

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What the Injury and Illness Proof of Loss Form Is

The Injury and Illness Proof of Loss Form documents a claimant's factual account and financial losses after a workplace injury or occupational illness. It collects claimant identity, incident details, medical treatment summary, lost wages, and requested benefits so the insurer or administrator can evaluate coverage, determine compensability, and calculate payments. The form often supports disability benefits, workers' compensation, or employer-based indemnity programs and becomes part of the official claim record once submitted to the insurer or claims administrator.

Why a Proper Proof of Loss Matters

A complete, accurate proof of loss speeds claim evaluation, reduces disputes, and preserves legal rights. It provides insurers with the evidence needed to determine coverage and payments while documenting dates and losses that affect statute-of-limitations and indemnity calculations.

Why a Proper Proof of Loss Matters

Who Completes and Reviews This Form

Accurate input from all parties reduces follow-up requests, shortens resolution time, and helps avoid denials or delayed benefit payments.

  • Claimants or employees submit first-hand incident facts and wage loss information to start the claim process.
  • Employers provide employment details, incident reports, and return-to-work dates that support the claimant's report.
  • Medical providers supply treatment summaries, diagnoses, and work restrictions to substantiate medical necessity.

Step-by-Step: Filling and Submitting the Form

Follow these sequential steps to prepare a clear, verifiable proof of loss before sending it to the insurer or claims administrator.

  • 01
    Gather records: Collect incident reports, medical records, and pay stubs to attach.
  • 02
    Complete fields: Enter dates, names, and amounts using the formats above.
  • 03
    Review accuracy: Verify names, dates, and totals to avoid rework.
  • 04
    Submit to insurer: Send via the insurer's preferred channel with attachments.

Key Sections to Expect on the Form

A professional proof of loss groups data into discrete sections so reviewers can find evidence quickly and consistently.

Claimant Details

Identity and contact information necessary for verification and correspondent routing, including DOB, SSN or TIN where required.

Incident Summary

Brief factual description of what happened, location, date/time, and any witnesses that corroborate events.

Medical Treatment

Diagnosis, treatment dates, provider details, and attachment list for records, imaging, and bills supporting medical expense claims.

Wage and Income

Detailed lost earnings calculation, pay period basis, overtime rules, and supporting pay documentation to substantiate benefit amounts.

Benefits Requested

Specify monetary amounts, disability benefits, reimbursement categories, or replacement services being claimed for the loss.

Certifications

Declarations and signature area where claimant attests to truthfulness under penalty of perjury or insurance contract terms.

Required Information Typically Collected

Claimant ID: Name and DOB
Contact Details: Phone and mailing address
Employer Info: Company name
Incident Date: MM/DD/YYYY
Medical Provider: Clinic or physician
Wage Details: Gross pay amount

Consequences of Incorrect or Late Filing

Claim Denial: Possible
Payment Delay: Likely
Statute Impact: Claims time-barred
Withholding Risk: Tax issues
Fraud Exposure: Investigation
Administrative Fees: Possible

Common Preparation Errors to Avoid

  • Incomplete attachments: failing to include medical reports or pay stubs often requires follow-up and slows adjudication.
  • Date inconsistencies: listing different incident or treatment dates across documents creates credibility issues and triggers requests for clarification.
  • Incorrect amounts: arithmetic errors in lost wage calculations commonly lead to benefit underpayment or later adjustments.
  • Signed but undated: signatures without dates can be rejected if the signature timing affects coverage or notice windows.

Typical Review and Adjudication Flow

Claims move through standardized stages from intake to final determination; each step requires specific documentation and time for review.

  • Intake: Claim logged and initial data verified.
  • Documentation: Medical and wage documents attached and screened.
  • Investigation: Adjuster reviews facts and coverage rules.
  • Decision: Payment, negotiation, or denial issued.

Configuring an Online Submission Workflow

Set up digital fields, signer steps, and authentication to match your insurer or employer process.

Field Configuration
Field Mapping Map PDF fields to database columns for automated intake.
Conditional Logic Show fields only when relevant to reduce signer errors.
Authentication Use email or SMS codes for signer verification.
Notifications Auto-alert reviewers and attach audit trail.

Digital Submission: Technical Considerations

Choose a platform that supports secure uploads, standard document formats, and required authentication.

  • File Formats: PDF, DOCX supported
  • Integrations: Works with major CRMs
  • Security: TLS and AES-256

Timing and Typical Deadlines

Notification and documentation deadlines vary by insurer and policy; submit promptly and verify policy-specific notice requirements to protect your claim rights.

Immediate Notice:

Report injury to employer as soon as possible.

Insurer Notice Window:

Commonly 20–90 days; check policy language.

Medical Records:

Attach promptly to avoid verification delays.

Statute of Limitations:

Varies by state; can bar late claims.

Follow-up Requests:

Respond quickly to information requests.

Comparison: eSignature Platforms for Submitting Proofs of Loss

Choose an eSignature provider that supports required compliance, file formats, and the workflow features your organization needs; signNow is listed first for vendor comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes Yes Yes Yes Yes
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Real-World Examples of Use and Outcomes

Illustrative examples show how organizations capture and process proofs of loss to resolve claims and document entitlement.

Optica Ventures — Claims Intake

Optica streamlined intake with standardized forms and attachments to reduce ambiguity in submissions.

  • The form captured medical and wage data efficiently.
  • The change reduced back-and-forth with carriers and helped the company close claim reviews more quickly while preserving documentation for audits and compliance.

Fertility Centers of Illinois — Patient Injury

The clinic used a consistent proof of loss template for staff injuries and treatment claims.

  • Providers attached concise treatment notes.
  • This practice improved administrative tracking, shortened adjudication timelines, and ensured retained medical records met HIPAA and retention requirements.

Frequently Asked Questions and Troubleshooting

Answers to common questions about completing, signing, and submitting the Injury and Illness Proof of Loss Form.


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