PLEASE COMPLETE IN FULL AND RETURN WITHIN 30 DAYS

PLEASE COMPLETE IN FULL AND RETURN WITHIN 30 DAYS Tel: 614.487.9680 Toll-free: 800.848.0123 www.uct.org Dear Member: We have received a request for a claim form, which is enclosed. Please follow these instructions in completing your claim form. 1. Print or Type all responses 2. To avoid delays, please complete all lines 3. Physician Statement must be completed by your doctor PLEASE SEND THE FOLLOWING: 4. A copy of the license of the facility 5. A copy of the Medicare Summary Notice, or E.O.B. 6. The bills for your facility confinement MAIL TO: United Commercial Travelers 1801 Watermark Drive, Suite 100 P.O. Box 159019 Columbus Oh 43215-8619 Sincerely and Fraternally, UCT Claim Department C-1008 Rev. 10-13 Enc

Claimant s Proof of Loss for Short-Term Care Insured's Name: Date of Birth: Policy No.: Address: Social Security No.: If someone else is handling this claim for you, give their name and address: Name: Address: Relationship: Phone No.: Please check the type of care you are claiming: Family Doctor: Full Name Address: Describe injury or sickness: Symptoms first noted: Dates of hospitalization: Admitted: Discharged: Name of Hospital: Full Name Phone No.: Address: Nursing Facility Care: Assisted Living Care: Home Health Care: Alternative Care: Please check the Activities of Daily Living with which you need assistance: Eating Dressing Toileting Transferring Continence Bathing Other: Full Name of the Caregiver/Facility: Phone No.: Address of Provider: Is this a result of an accident? Yes No If Yes, please specify: Auto accident Other Is other Insurance paying for this/these services? Yes No If Yes, please complete the information below. Carrier Name: Phone No.: Address of Carrier: Effective Date of Policy: Policy Number: If there is more than one insurance carrier paying for this/these services please reference the information on a separate sheet of paper. Please include a copy of any billing you have received for the service(s) indicated above with your completed claimant's statement. In Arizona: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. In Other States: 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. Please complete the authorization form to help expedite the processing of your claim. C-CPOL 06/09

Attending Physician s Statement for Short-Term Care ATTN: Claims Department PATIENT'S NAME: MUST BE COMPLETED BY PHYSICIAN Date of Birth: Policy Number: 1. Primary Diagnosis/ICD9 Code: Date of Onset: Secondary Diagnosis/ICD9 Code: Date of Onset: 2. Date you last saw this patient: Reason for visit: 3. Are any of the following services necessary? Please check all that apply. RN Homemaker Occupational Therapist Certified Aide Physical Therapist Speech Therapist Other: 4. Care Setting: Nursing Home Adult Day Care Personal Residence Assisted Living Facility Other: 5. (ADLs) Bathing/Showering/Sponge Transferring Continence Bladder/Bowel Eating Toileting Dressing Performs completely independently Performs independently using assistance device Able to complete only with cueing or supervision of another person Requires some human assistance with certain elements of task Requires substantial assistance from another person to complete 6. Expected amount of care required: Hours/Day Days/Week Weeks/Months Note: Recommendations for the care described above are theoretical, based upon your observations. A definitive opinion of the need for the services is based upon all documentation including, but not limited to, assessments, medial records, and actual utilization of support services. 7. Should this patient be capable of returning to prior level of independence with rehabilitation? Yes No If No, why? 8. If this care was not available, would this patient require nursing facility confinement? Yes No lf Yes, why? This request is for general medical information. Additional medical information may be required. Thank you for completing this form; please mail or fax to address and fax number at top of form. Physician Signature: Date: Name and Address of Attending Physician: ANY COST INCURRED FOR COMPLETION OF THIS FORM IS THE RESPONSIBILITY OF THE PATIENT. C-APS 06/09

Facility Certificate of Care for Short-Term Care ATTN: Claims Department 1. Please read and sign. (Use blue or black ink only.) 2. Give this form to the Facility for completion. INSTRUCTIONS FOR CLAIMANT: Claimant Name: Signature of Claimant: Policy Number: Date: INSTRUCTIONS FOR THE CARE FACILITY: 1. Please complete this form, and attach a copy of: a) Physician's signed plan of care - including the diagnosis and treatments prescribed. b) Initial assessment. c) Copy of the license for the unit where the Insured is confined. d) Narrative charting, nurses notes and CNA flow sheets. 2. Please return the completed form and copies to the address above. Name of Facility: Facility Address: Phone No.: ( ) Number of Beds: Initial Admission Date: Discharge Date: Subsequent Admission(s): Patient admitted from: Residence Hospital Other: Diagnosis on Admission: Secondary Diagnosis: Name of Attending Physician: Is Patient's Stay Insurance-Approved? Yes No If Yes, list dates approved: FACILITY'S EVALUATION OF PATIENT'S LEVEL OF CARE: FROM: TO: FROM: TO: Skilled / / / / Independent Living / / / / Intermediate / / / / Retirement Facility / / / / Assisted Living / / / / Other / / / / C-FCC 06/09 1

Facility Certificate of Care for Short-Term Care Continued PATIENT S NAME: Policy Number: MENTAL AND COGNITIVE STATUS: Describe client's assistance with medications: Facility policy to administer Client self-administers Assistance provided Describe: Does your facility document in a clinical record? Yes No If Yes, how often? Does the facility maintain control and records of medications given? Yes No ACTIVITIES OF DAILY LIVING (ADLs): (ADLs) Bathing/Showering/Sponge Transferring Continence Bladder/Bowel Eating Toileting Dressing Performs completely independently Performs independently using assistance device Able to complete only with cueing or supervision of another person Requires some human assistance with certain elements of task Requires substantial assistance from another person to complete *Record details of any assistance needed, including type of assistance, how often it is provided, and who provides the assistance: If more space is needed, attach a signed and dated sheet and check this box. (check only if additional sheet is submitted) List any assisting devices used by patient (wheelchair, walker, cane, etc.) FACILITY INFORMATION: Does the facility have a Medical Director or MD available to furnish medical care in case of an emergency? Yes No If Yes, Name: Employee of facility? Yes No Is there a nurse supervising care? Yes No If Yes, how often is the nurse physically present at the facility? Hours/Day Days/Week How often is nurse on call? Hours/Day Days/Week Is this care provided under a physician's plan of care? Yes No If Yes, how often is the POC updated? Signature of Director of Nursing or Nurse Manager: Title: Date: For Your Protection State Insurance Laws require the following to appear on this form: Any Person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement In State prison. ANY COST INCURRED TO COMPLETE THIS FORM IS THE PATIENT S RESONSIBILITY. C-FCC 06/09 2

Monthly Verification of Continuing Care for Short-Term Care ATTN: Claims Department PART A Complete Parts A & B for each month the resident is confined and attach the itemized bill. (Use blue or black ink only.) Form submitted for dates of service from: to: 1. Resident Name: Policy No.: DOB: 2. Name of Facility: 3. Facility Address: 4. Phone No.: ( ) 5. Initial Admission Date: Discharge Date: 6. Subsequent Admission(s) 7. Diagnosis on Admission: 8. Secondary Diagnosis: 9. Remained in the facility with NO out of facility date. 10. Remained in the facility with the exception of the following date(s). Left on: Returned on: Bed Hold Charge: Yes No Reason: Left on: Returned on: Bed Hold Charge: Yes No Reason: Left on: Returned on: Bed Hold Charge: Yes No Reason: 11. Name of Attending Physician: Phone No.: ( ) 12. Is Resident's Stay insurance Approved? Yes No If Yes, list dates approved: 13. FACILITY'S EVALUATION OF PATIENT'S LEVEL OF CARE: FROM: TO: FROM: TO: Skilled / / / / Independent Living / / / / Intermediate / / / / Retirement Facility / / / / Assisted Living / / / / Other / / / / C-MVCC 06/09 1

Monthly Verification of Continuing Care for Short-Term Care Continued PART B RESIDENT'S NAME: POLICY NO.: MENTAL AND COGNITIVE STATUS: 14. Describe resident's assistance with medications. Facility policy to administer Client self-administers Assistance provided Describe: Does your facility document in a clinical record? Yes No If Yes, how often? 15. Does your facility document in a clinical record? Yes No If Yes, how often? ACTIVITIES OF DAILY LIVING (ADLs): (ADLs) Bathing/Showering/Sponge Transferring Continence Bladder/Bowel Eating Toileting Dressing Performs completely independently Performs independently using assistance device Able to complete only with cueing or supervision of another person Requires some human assistance with certain elements of task Requires substantial assistance from another person to complete *Record details of any assistance needed, including type of assistance, how often it is provided, and who provides the assistance: List any assisting devices used by resident (wheelchair, walker, cane, etc.): lf more space is needed, attach a signed and dated sheet and check this box. (check only if additional sheet is submitted) Signature of Director of Nursing or Nursing Manager: For Your Protection State Insurance Laws require the following to appear on this form: Any Person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement In State prison. ANY COST INCURRED TO FILL OUT THIS FORM IS THE PATIENT S RESPONSIBILITY. C-MVCC 06/09 2