Disability Claim/Premium Waiver 

We market the disability benefit in life and cancer insurance policies as disability income or waiver of premium payments. It is important to submit the specified documents to expedite the claim process. Please review the benefits contained in your policy contract.

• Claim Form – Fully completed disability claim form CL-0285-10 (R-1018)
• Claimant – the primary policyholder named on the insurance application to whom all payments will be issued
• Electronic Deposit Authorization –  Must be signed by the insured and the holder of the account where the electronic deposit is to be made, submitted along with supporting documentation including bank account number (Account Statement, Void Check, Bank Account Certification)
• Employer Certification – Form completed in its entirety by the employer’s Human Resources Officer, with employer seal (if applicable)
• Medical Certification – Completed by the physician certifying the insured as disabled for the claimed condition.

Requirements to claim Total Physical Disability policies due to Illness or Accident:

• Copy of the record of the physician who certifies the claimed disability, including:
  •  Copy of study results and medication lists
  • Progress Notes for the claimed condition
• Documents that must be submitted with all policy claims with less than two years of enforcement as of the date of the loss:
  • Authorization to request medical information signed by the insured POS-0190-42 (R-0606)
  • Copy of photo ID with signature of insured (patient)
  • Additional Requirements Form to list the names of doctors and hospitals including address, phone numbers, and specialty of the doctors CL-0501-106 (R-0103) who have treated you in the last two years.
  • Use of the detailed medical plan with the dates of medical services, provider name, diagnosis code prior to two years from the issuance of the policy.

• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical Certificate (Form 1021)
  • Administrator’s Decision Regarding Medical Treatment (Form 395)
  • Employer Report (Form 373) completed by the employer at the time of the accident

For more information on disability insurance, click here. 

Cancer Policy Claim or First Cancer Diagnosis Endorsement

To claim cancer benefits or endorsements, it is important to submit the documents listed in the following benefits to expedite the claim process, as applicable. Please review the benefits included in your policy contract

Requirements to claim benefits under cancer policies

Documents to be submitted for cancer and dread disease, and hospitalization claims for any disease with losses occurring within six (6) months of the effective date of the policy.

• Medical certificate, CL-1207-126 (R-0221). diagnosing the following:
  • Cancer – Completed by the physician treating your cancer condition, not the surgeon or other physician not directly involved in the treatment.
  • Dread Disease – Completed by the physician who diagnoses the illness claimed and covered by your policy.
• Authorization to request medical information signed by the patient over the age of 21, or signed by the guardian in the case of a minor. POS-0190-42 (R-0606)
• Copy of the patient’s photo ID with signature if of legal age, or the patient’s guardian.
• List of names of physicians and hospitals including telephone numbers, address, and specialty of physicians from the last 2 years. CL-0207-166 (R-0721)
• Copy of the record of the past 2 years, prior to the issuance of the policy by the physician who started treating you for the claimed condition.
• Detailed medical plan utilization with dates of medical services received, including diagnosis codes, for the 2 years prior to when the policy was issued.

Please include the following for any dependents or children with disabilities:

• For children who are neither biological nor adopted, but who depend on the insured, you must submit a copy of the income tax return or the final decree of adoption.
• Dependents with Disabilities: Attach a medical certification attesting to the disability of the claimed dependent.

Cancer Policy Claim form:

CL-1207-126 (R-0221). completed and signed by:

• Claimant – primary policyholder named in the insurance application to whom all payments will be made, including claims from his or her dependents or, in the event of his or her death, to the beneficiary designated in said application.
• Electronic Deposit Authorization – Must be signed by the insured and the holder of the account where the electronic deposit is to be made, submit along with supporting documentation including bank account number (Account Statement, Void Check, Bank Account Certification).
• Hospital Certification – Form completed by the hospital’s medical records official certifying admission to a regular room or intensive care unit (if applicable).
• Primary Care Physician Certification – For cancer or dread disease claims, complete only on the initial claim by the physician who first discovered the condition in the claim.

Benefits to claim (it is important to review what is included in your policy)

Health Maintenance

• Health Maintenance Benefit Claim Form CL-1016-170 (R-1018)
• Invoice or result showing the date of preventive screening tests performed, such as: mammograms, Papanicolaou (PAP), and prostate-specific antigen (PSA) tests, and others with a similar purpose, as per policy.

Tests and Initial Diagnosis for Cancer and/or Dread Diseases

• Positive Pathology Report for cancer (biopsy performed)
  • In case of Dread Diseases: Certification from the physician who initiated treatment for the condition claimed, along with the medical studies claimed
• Invoice for medical tests performed to reach the first diagnosis (X-rays, CT scan, MRI, biopsy, laboratories, etc.)
• Results of medical tests performed to reach the first diagnosis (X-rays, CT, MRI, laboratories, etc.)

Waiver of Premium

• Be the primary policyholder and have received a positive Cancer diagnosis (other than skin cancer)

Hospital, Drugs, and Prolonged Hospitalization Coverage

• Admission form and discharge summary or certification from a medical records official indicating dates and times of admission and discharge with diagnoses for the hospitalization
• Studies performed (pathologies, MRI, CT scan, etc.) and progress notes during hospitalization

Compensation for Disability or Loss of Income while Hospitalized

• Be the primary policyholder and have been working at the time of hospitalization due to cancer or dread disease

Intensive Care

• Certification from medical records department stating diagnosis, date and time of intensive care unit admission and discharge OR nurse’s notes from intensive care unit admission and discharge
• Admission sheet and discharge summary

Surgery and Anesthesia

• Surgery Report
• Surgical pathology result (biopsy result)
• Surgeon’s invoice with date, cost, and procedure code

Blood and Plasma

• Hospital invoice with dates, codes, and charges for administered blood and/or plasma
• Record with the date of the blood and/or plasma transfusion performed

Blood Substitute

• Record of transfusion performed or evidence of alternative treatment with date, cost, and treatment code.
• Receipt of payment made for treatment

Radiotherapy, Chemotherapy, and Experimental Therapy

• Chemotherapy, Radiotherapy and Administration Claim Form. CL-0219-174.
• Invoice or receipt with name, cost, code, and date of chemotherapy, radiotherapy, or experimental therapy or use of the medical plan.
• Pharmacy certification with date, name, and cost of the medication (if applicable)

Medications for chemotherapy-induced nausea

• Payment receipt for chemotherapy-induced nausea medication with date and cost

X-rays, CT Scan, and MRI

• Invoice or payment receipt for the study performed, including the date of the study.

Breast Prosthesis and other Prostheses

• Prosthesis acquisition invoice.

Breast Reconstruction

• Breast reconstruction surgery report
• Invoice from the surgeon who performed the breast reconstruction

Skin Cancer

• Positive pathology report for skin cancer test (biopsy)
• Removal or Mohs surgery report
• Dermatologist invoice with date, code and cost of skin cancer removal or treatment

Human Papillomavirus Vaccine for girls ages 11 to 18

• Payment receipt with vaccine name, date, and cost.

Ambulance

• Having been admitted to a hospital for cancer or dread disease treatment
• Ambulance invoice with date of service provided

Air Transportation for the Insured

• Medical order from a hematologist-oncologist certifying treatment in an institution outside of Puerto Rico
• Receipt for purchase of airfare at regular rate
• Medical evidence of treatment received outside of Puerto Rico

Air Transportation and Lodging for the Family Member or Companion

• Receipt for purchase of airfare at regular rate for the companion
• Receipt of payment for accommodation outside Puerto Rico for adult companion 

Ground Transportation

• Medical order from a hematologist-oncologist certifying treatment in an institution outside of Puerto Rico
• Payment receipt for car rental outside of Puerto Rico

Homemaker Service

• Medical order justifying the need for homemaker services
• Payment receipt for services showing the date and costs

Psychological Support

• Medical order justifying the need for psychological services

• Payment receipt showing the date and costs of services

• Evidence of medical visits

Personal Physician

• Personal physician visit notes during hospitalization
• Invoice for hospital visits, excluding post-operative visits

Private Nursing Care Services

• Medical order justifying the need for private nursing care services at the hospital
• Receipt of payments made for private nursing care services at the hospital with dates

Second Surgical Opinion

• Second surgical opinion medical consultation sheet
• Surgeon’s invoice for the medical visit for the second opinion.

Additional Compensation for Working Parents

• Employer certification of exhausted leave periods or copies of pay stubs

Erectile Dysfunction

• Medical order justifying the need for surgical procedure or medication to treat erectile dysfunction
• Payment receipt with date and cost of medical procedure or medication

Convalescent Home

• Medical order requiring stay in a convalescent home

• Hospital discharge sheet prior to convalescent home.

• Invoice for convalescent home stay or convalescent home discharge summary.

Quality of Life

• Medical order justifying the need for the items or services specified in the policy.
• Payment receipt with date and costs of the items or services received

Terminal Cancer Hospice Care Services

• Medical order with terminal cancer diagnosis recommending hospice care
• Discharge form from hospital admission prior to going into hospice care.

Pain Management and Side Effects (includes cannabis, among others)

• Payment receipt for pain management treatment with dates
• Medical order from physician in charge of treatment

Legal Services

• Receipt showing the date and fees paid to the lawyer who provided services following the death of the Insured

Transfer of Remains to Puerto Rico

• Payment receipt from the funeral home that prepares the insured’s remains and the airfare for repatriation to Puerto Rico.

Funeral Expenses

• Death claim form completed by the claimant (primary policyholder in case of deceased dependent, or beneficiary if primary policyholder is deceased) CL-0586-58 (R-0324).
• Copy of claimant’s Social Security card

• Copy of claimant’s photo ID with signature
• Original death certificate (form RD-77) with the cause of death

• Payment receipt with the name of the person who paid for the funeral service.

If the funeral service has not been paid for, you must include:

• Invoice and detailed contract for the insured’s funeral service.

• Notice of Law No. 230, Anti-Fraud Act (signed by funeral director) CL-1207-122(R-0418).
• Assignment of Proceeds of Insurance form authorizing the pending payment to the funeral home, signed by the beneficiary (primary policyholder in the case of a deceased dependent, or the beneficiary in the case of the death of the primary policyholder) CL-1207-125 (R-0816).

• Copy of the identification with signature of the person who signs the Assignment of Proceeds of Insurance form.

Postmortem Diagnosis

• Death Claim Form completed and signed by the claimant CL-0586-58 (R-0324)
• Copy of claimant’s identification with signature
• Death Certificate (Form RD-77).
• Medical record of the admission that includes studies performed for the hospitalization period prior to the date of death, or certification from a medical records official indicating the dates and diagnoses of the hospitalization.
• Detailed hospital bill

For more information on cancer insurance, click here. 

Additional Benefits Claim

To claim the additional acquired benefits, it is important to submit the documents indicated in the benefits to be claimed. This will help us expedite your claim process. Please review the benefits included in your policy contract.

Claim Form:

• Claimant – primary policyholder named in the insurance application to whom all payments will be made, including claims from his or her dependents or, in the event of his or her death, to the beneficiary designated in said application.
• Electronic Deposit Authorization – Must be signed by the insured or claimant, holder of the account where the electronic deposit is to be made, submit along with supporting documentation including bank account number (Account Statement, Void Check, Bank Account Certification).

• Hospital Certification – Form completed by the hospital’s medical records official certifying admission to a regular room or intensive care unit (if applicable).

• Physician Certification – Completed by the physician who started the treatment for the claimed condition (if applicable).

Accidental Death

• Death Claim Form completed by the claimant CL-0586-58 (R-0324)
• Copy of claimant’s Social Security card
• Copy of claimant’s photo ID with signature (legible)
• Original death certificate (Form RD-77) with the cause of death
• Initial, supplemental, and final police reports (if applicable)

Hospitalization Due to Accident /Hospitalization Due to Accident 24 hours

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614), CL-0801-107 (R-1018)
• Admission form and discharge summary or certification from a medical records official indicating hospitalization dates and diagnoses
• Initial, supplemental, and final police reports (if applicable)

Accidental Dismemberment

• Accidental dismemberment claim form completed and signed by the claimant CL-0208-127 (R-0221)
• Medical certification and/or surgery report with the details of the affected areas.
• Initial, supplemental, and final police reports (if applicable)

Emergency Medical Treatment Due to Accident

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614), CL-0801-107 (R-1018).
• Payment receipt with payment date for the claimed service
• Emergency room triage notes
• Triage nurse’s notes
• Surgery report (if applicable)
• Notes from visits after the accident

Burns, Fractures, Tendons and Ligaments, Bruises, Dislocations, and Mutilations

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614), CL-0801-107 (R-1018).
• Medical evaluation form
  • In the case of a burn, indicate the degree of burn and the percentage of body surface area affected.
• Triage nurse’s notes
• X-rays results within 72 hours of the accident (if applicable)
• Invoice or notes from medical visits after the accident, if applicable
• Police report (if applicable)
• Surgery report (if applicable)
• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical Certificate (Form 1021)
  • Administrator’s Decision Regarding Medical Treatment (Form 395)
  • Employer Report (Form 373) completed by the employer at the time of the accident

Home Health Care Due to Accident

• Accident policy claim form completed and signed by claimant CL-0704-111 (R-0221).
• Medical certification including convalescence period
• Admission form and discharge summary or certification from a medical records official indicating dates of the accident-related hospitalization and diagnoses, if applicable.
• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical certificate from the State Insurance Fund Corporation (Form CFSE-1021), if applicable.
  • Administrator’s Decision Regarding Medical Treatment (Form 395)

Hospitalization Due to Illness

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).
• Admission form and discharge summary or certification from a medical records official indicating hospitalization dates and diagnoses

Intensive Care

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).
• Certification from a medical records official indicating diagnosis(es), date, time of admission and discharge, or intensive care unit admission nursing notes

Total Physical Disability

• Disability claim form completed in its entirety by claimant, Employer, and physician who certifies the disability CL-0285-10 (R-0221).

• Copy of the record of the physician who certifies the claimed disability, including:
  •  Copy of study results and medication lists
  • Progress Notes for the claimed condition
• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical Certificate (Form 1021)
  • Administrator’s Decision Regarding Medical Treatment (Form 395)
  • Employer Report (Form 373) completed by the employer at the time of the accident

Organ Transplant

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).
• Medical certification completed by specialist who performs the transplant
• Surgical report of the transplant performed
• Certification of assistance from the Puerto Rico Department of Health’s Fund for Services Against Remediable Catastrophic Illnesses CL-1015-154

We will pay 100% of the expenses incurred and paid by the insured in excess after the compensation benefit, subject to the terms and limits of the supplement. To file a claim, please submit the following:

• Details of payments not covered by other health insurance or insurance coverage
• Itemized payment receipts for deductibles or copayments
• Itemized invoice from the hospital where the transplant was performed
• Health plan or catastrophic health plan utilization and total services paid, including those not covered by Medicare (provide Medicare breakdown)
• Receipts for transportation, lodging, and meals
• Detailed payment receipt for private nursing care services

First Heart Attack Diagnosis and First Major Heart Surgery

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).
• Progress Notes from the physician certifying the claimed condition, along with studies performed (heart sonogram, catheterization report, etc.)
• Major heart surgery report (if applicable)
• Copy of medical records from the hospital, including labs and studies performed (if applicable)
• Detailed hospital bill

First Cancer Diagnosis

• First cancer diagnosis policy claim form completed and signed by claimant and primary care physician CL-1207-126 (R-0221).

• Positive pathology report for cancer diagnosis

Blood Substitute

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).

• Record of transfusion performed or evidence of alternative treatment with date, cost, and treatment code.
• Receipt of payment made for treatment

Radiotherapy, Chemotherapy, and Experimental Therapy

• Chemotherapy, Radiotherapy and Administration Claim Form. CL-0219-174
• Medical order with name, cost, code, and date of chemotherapy, radiotherapy, or experimental therapy service to be administered to the insured, or the invoice with name, cost, code, and date of chemotherapy, radiotherapy, or experimental therapy service, or the utilization of the medical plan.

Life Insurance Claim

To claim death benefits, it is important to submit the documents indicated below to expedite your claim process. Please review the benefits contained in your policy contract.

Claim Form:

• Claim form Fully completed Death Claim Form CL-0586-58 (R-0324)
  • Claimant – the beneficiary(ies) named on the insurance application to whom all payments will be issued, including claims for dependents or upon your death.
• Electronic Deposit Authorization – Must be signed by the beneficiary and the holder of the account where the electronic deposit is to be made, submit along with supporting documentation including bank account number (Account Statement, Void Check, Bank Account Certification)
• Primary Care Physician Certification – completed by the doctor who treats the disease diagnosed in the causes of death. (To be completed only on policies issued less than two years prior to the date of the insured’s death)

Requirements for claiming benefits in policies for losses occurring less than two years from the date of the policy’s issuance.

• Completed medical certificate CL-0586-58 (R-0324).
• Authorization to request medical information signed by the beneficiary over the age of 21, spouse, children or parents. POS-0190-42 (R-0606).
• Copy of photo ID and signature of the person signing the authorization to request medical information.
• List of names of physicians and hospitals including telephone numbers, address, and specialty of physicians who have treated the insured in the last 2 years CL-0207-166 (R-0721).
• Copy of records from hospitals and physicians who treated the insured during the last 2 years before the policy was issued.
• Detailed medical plan utilization with dates of medical services received and provider names, including diagnosis codes, for the 2 years prior to when the policy was issued.
• Copy of Death Certificate model RD-77

Requirements to Claim Accidental, Natural, or Illness Death benefits

• Fully completed Death Claim Form CL-0586-58 (R-0324)
• Copy of Death Certificate (preferably, Form RD-77)
• Claimant’s (beneficiary[es]) photo ID with signature
• Copy of claimant’s (beneficiary[es]) Social Security card

Special Cases:

• If the beneficiary or one of the beneficiaries is a minor, please submit the following:
  • Birth certificate of the minor issued by the Demographic Registry within the last 6 months.
  • Copy of the minor’s Social Security card
  • Name, mailing address, and phone number of the minor’s guardian
  • Minor’s photo ID with signature (if applicable)

• Beneficiary with a disability:
  • Attach a medical certification attesting to the beneficiary’s disability.
  • Name, mailing address, and telephone number of the guardian of the beneficiary with disability
  • Copy of the Social Security card of the beneficiary with disability
  • Photo ID with signature of the beneficiary with disability

• If the cause of death is due to homicide or an accident, please submit the following:
  • Initial, supplemental, and final police reports
  • Autopsy and toxicology report (in case of accident)
  • Authorization to request autopsy and toxicology report (only in case of homicide) CL-0210-129 (R-1012)
• Beneficiary is the mortgage bank:
  • Loan balance letter from mortgage bank

• If, at the time of the insured’s death, the primary beneficiary is deceased, but the contingent beneficiary is alive, please submit
  • Primary beneficiary’s death certificate

• If, at the time of the insured’s death, the designated beneficiary is deceased and there is no other designated beneficiary, please submit the following:
  • Beneficiary’s death certificate
  • The insured’s declaration of heirs if the policy benefit is greater than $5,001
    • For policies where the benefit is less than $5,000, provide an affidavit stating the names of the insured’s sole heirs signed by all named heirs.

• If, at the time of the insured’s death, the beneficiary dies after the beneficiary and there is no other designated beneficiary, please submit the following:
  • Beneficiary’s death certificate
  • The beneficiary’s declaration of heirs, if the policy benefit is greater than $5,001
    • For policies where the benefit is less than $5,000, provide an affidavit stating the names of the beneficiary’s sole heirs signed by all named heirs.

Beneficiary designates a payment to the funeral home:

• Copy of the funeral service contract signed by the claimant and the funeral director
• Detailed invoice from the funeral home signed by the funeral director.
• Notice of Law No. 230, Anti-Fraud Act signed by funeral director CL-1207-122 (R-0418)
• Designation of benefits authorizing pending payment to the funeral home signed by beneficiary, CL-1207-125 (R-0816).
• Copy of ID with signature of the person who signs the designation
• Copy of Death Certificate (preferably, Form RD-77)

For more information on Life Insurance, click here. 

The unemployment benefit is acquired in life insurance policies as compensation for loss of employment. It is important to submit the specified documents to expedite the claim process. Please review the benefits contained in your policy contract.

• Claim form with all components completed by the insured and the employer, CL-0815-150 (221).
• Letter of termination stating reason for termination, hours worked, length of employment, and date of termination
• Copy of pay stubs showing hours worked
• Copy of the eligibility letter (approval) from the Unemployment Insurance Division, wage transcript form, and monetary determination.
• Copy of paid pay stubs or electronic Unemployment Certification for each week you continued receiving benefits

The Accelerated Benefit Rider is acquired on life insurance policies as compensation for a diagnosis of the conditions specified in your policy or when receiving a diagnosis with a life expectancy of one year or less. It is important to submit the specified documents to expedite the claim process. Please review the benefits contained in your policy contract.

• Accelerated supplement claim form completed and signed by claimant CL-0615-149.
• Claim form completed by your diagnosing physician CL-0805-112.
• Medical Progress Notes certifying the claimed condition, along with studies performed.
• Results of medical tests performed to reach the diagnosis (X-rays, CT scan, MRI, laboratories, biopsy, etc.) (if applicable).
• Copy of medical records from the hospital, including laboratories and studies performed (if applicable).

COMPENSATION POLICY FOR HOSPITALIZATION

 DUE TO HEART DISEASE,

HEART ATTACK, AND STROKE

REQUIREMENTS TO CLAIM BENEFITS

To claim benefits under the basic coverage or its endorsements, it is important to submit the documents indicated in the following benefits to expedite the claim process. Please review the benefits included in your policy contract.

Claim Form:

Completed and signed, CL-1207-126 (R-0221). by:

• Claimant – primary policyholder named in the insurance application to whom all payments will be made, including claims from his or her dependents or, in the event of his or her death, to the beneficiary designated in said application.
• Electronic Deposit Authorization – Must be signed by the insured and the holder of the account where the electronic deposit is to be made, submit along with supporting documentation including bank account number (Account Statement, Void Check, Bank Account Certification).
• Hospital Certification – Form completed by the hospital’s medical records official certifying admission to a regular room or intensive care unit (if applicable).
• Primary Care Physician Certification – completed by the physician treating the claimed condition (cardiologist, neurologist, etc.).

Requirements to claim benefits on policies for losses occurring within six (6) months or less of the effective date of the policy:

• Completed medical certificate, CL-1207-126 (R-0221).
• Authorization to request medical information, signed by the patient over the age of 21 POS-0190-42 (R-0606) or signed by the guardian if the patient is a minor.
• Copy of the patient’s photo ID with signature if of legal age, or the patient’s guardian
• List of names of physicians and hospitals including telephone numbers, addresses, and specialty of physicians from the last 2 years. CL-0207-166 (R-0721).
• Copy of the record of the past 2 years, prior to the issuance of the policy by the physician who started treating you for the claimed condition.
• Detailed medical plan utilization with dates of medical services received, including diagnosis codes, for the 2 years prior to when the policy was issued.

Diagnostic Tests for Heart Attack or Stroke

• Claim form completed and signed by claimant and the cardiologist or internist, CL-1207-126 (R-0221).
• Medical records by diagnosis:

• Heart Attack Requirements:
  • Studies of cardiac enzymes in the blood (Creatine Kinase MB)
  • Catheterization with more than 75% narrowing of the artery
  • Abnormal electrocardiogram report
• Stroke Requirements:
  • CT scan of the brain to diagnose acute rupture or cerebral artery occlusion

Hospitalization and Medicine

• Admission form and discharge summary, or certification from a medical records official, indicating dates of hospitalization and diagnoses, as well as dates of admission and discharge
  • Heart Attack Requirements:
    • Medical certification of the claim form completed by the cardiologist or internist
    • Studies of cardiac enzymes in the blood (Creatine Kinase MB)
    • Catheterization with more than 75% narrowing of the artery
    • Abnormal electrocardiogram report
  • Stroke Requirements:
    • CT scan of the brain to diagnose acute rupture or cerebral artery occlusion

Surgery and Anesthesia

• Invoice for the surgery and/or procedure from the surgeon indicating the cost, code, and date of service, or health plan utilization report indicating the procedure performed.
• Surgery report

Ambulatory Surgery Center

• Proof of ambulatory surgery center utilization

Blood and Plasma

• Hospital invoice with date and code of the component received, blood or plasma
• Blood or plasma transfusion record with date of receipt

Electrocardiogram (hospitalized in a regular room)

• Electrocardiogram invoice or study

Oxygen (admitted to a hospital)

Oxygen invoice

Ambulance

• Invoice for ambulance charges
• Admission and discharge forms 

Ground or Air Transportation and Accommodation for the Insured

• Medical order certifying treatment if not available locally
• Receipt for the purchase of airfare at regular rate with date
• For ground transportation, proof of mileage to the place of treatment
• Accommodation payment receipt

Air Transportation and Lodging for the Family Member or Companion

• Medical order certifying that treatment is not available locally
• Receipt for the purchase of a regular fare air ticket for an adult companion with date
• Payment receipt for adult companion lodging (hotel)

Second and third surgical opinion

• Medical note of consultation for a second or third surgical opinion.
• Consultation invoice or specialized study for second or third surgical opinion.

Private nursing services (admitted to a hospital)

• Medical order justifying the need for private nursing services at the hospital.
• Invoice with detailed date for private nursing services

Primary Care Physician Other than the Surgeon

• Admission and discharge forms
• Detailed hospitalization bill indicating the primary care physician charges

Physiotherapy

• Medical order justifying the need for physiotherapy services
• Invoice for physical therapy received with date.

Heart Transplant

• Medical certification completed by specialist who performs the transplant
• Surgical report of the transplant performed
• Certification of assistance from the Puerto Rico Department of Health’s Fund for Services Against Remediable Catastrophic Illnesses CL-1015-154
• Surgeon’s invoice with date of surgery performed

Home Care Nurse (admitted to the hospital)

• Medical order justifying the need for nursing care services
• Detailed invoice for daily nursing services

Medical Equipment for Home Use

• Medical order justifying the use of medical equipment at home
• Invoice with date and cost for durable equipment rental

Hospice

• Admission and discharge forms
• Primary care physician certification regarding the patient’s prognosis of 6 months or less to live

To claim benefits under the basic coverage or its endorsements, it is important to submit the documents indicated in the following benefits to expedite the claim process. Please review the benefits contained in your policy contract.

 Claim form:

• Claimant – primary policyholder named in the insurance application to whom all payments will be made, including claims from his or her dependents or, in the event of his or her death, to the beneficiary designated in said application.
• Electronic Deposit Authorization – Must be signed by the insured and the holder of the account where the electronic deposit is to be made, submit along with supporting documentation including bank account number (Account Statement, Void Check, Bank Account Certification)
• Hospital Certification – Form completed by the hospital’s medical records official certifying admission to a regular room or intensive care unit (if applicable).
• Physician Certification – Completed by the physician who started the treatment for the claimed condition (if applicable)

Accidental Death

• Death Claim Form completed by the claimant CL-0586-58 (R-0324)
• Copy of claimant’s Social Security card
• Copy of claimant’s photo ID with signature (legible)
• Original death certificate (Form RD-77) with the cause of death
• Initial, supplemental, and final police reports (if applicable)
• Autopsy and toxicology report (in case of accident)
  • Authorization to request autopsy and toxicology report (only in case of homicide) CL-0210-129 (R-1012)

Special Cases:

• If the beneficiary or one of the beneficiaries is a minor, please submit the following:
  • Birth certificate of the minor issued by the Demographic Registry within the last 6 months.
  • Copy of the minor’s Social Security card
  • Name, mailing address, and phone number of the minor’s guardian
  • Minor’s photo ID with signature (if applicable)

• Beneficiary with a disability:
  • Attach a medical certification attesting to the beneficiary’s disability.
  • Name, mailing address, and telephone number of the guardian of the beneficiary with disability
  • Copy of the Social Security card of the beneficiary with disability
  • Photo ID with signature of the beneficiary with disability

• If the beneficiary or one of the beneficiaries is a minor, please submit the following:
  • Birth certificate of the minor issued by the Demographic Registry within the last 6 months.
  • Copy of the minor’s Social Security card
  • Name, mailing address, and phone number of the minor’s guardian

• If, at the time of the insured’s death, the primary beneficiary is deceased but the contingent beneficiary is alive, please submit
  • Primary beneficiary’s death certificate

• If, at the time of the insured’s death, the designated beneficiary is deceased and there is no other designated beneficiary, please submit the following:
  • Beneficiary’s death certificate
  • The insured’s declaration of heirs if the policy benefit is greater than $5,001
    • For policies where the benefit is less than $5,000, provide an affidavit stating the names of the insured’s sole heirs signed by all named heirs.

• If, at the time of the insured’s death, the beneficiary dies after the beneficiary and there is no other designated beneficiary, please submit the following:
  • Beneficiary’s death certificate
  • The beneficiary’s declaration of heirs if the policy benefit is greater than $5,001
    • For policies where the benefit is less than $5,000, provide an affidavit stating the names of the beneficiary’s sole heirs signed by all named heirs.

Hospitalization Due to Accident /Hospitalization Due to Accident 24 hours

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614), CL-0801-107 (R-1018).
• Admission form and discharge summary or certification from a medical records official indicating hospitalization dates and diagnoses
• Initial, supplemental, and final police reports (if applicable)

Accidental Dismemberment

• Accidental dismemberment claim form completed and signed by the claimant CL-0208-127 (R-0221)
• Medical certification and/or surgery report with the details of the affected areas.
• Initial, supplemental, and final police reports (if applicable)

Emergency Medical Treatment Due to Accident

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614), CL-0801-107 (R-1018).
• Detailed payment receipt that includes the date of service
• Emergency room triage notes
• Triage nurse’s notes
• Surgery report (if applicable)
• Notes from visits after the accident

Burns, Fractures, Tendons and Ligaments, Bruises, Dislocations, and Mutilations

• Accident benefit claim form completed and signed by claimant CL-0801-107 (R-0614), CL-0801-107 (R-1018).
• Medical evaluation form
  • In the case of a burn, indicate the degree of burn and the percentage of body surface area affected.
• Triage nurse’s notes
• X-rays results within 72 hours of the accident (if applicable)
• Invoice or notes from medical visits after the accident, if applicable
• Police report, if applicable
• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical Certificate (Form 1021)
  • Administrator’s Decision Regarding Medical Treatment (Form 395)
  • Employer Report (Form 373) completed by the employer at the time of the accident

Home Health Care Due to Accident

• Accident policy claim form completed and signed by claimant, CL-0704-111 (R-0221).
• Medical certification including convalescence period
• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical certificate from the State Insurance Fund Corporation (Form CFSE-1021), if applicable.
  • Administrator’s Decision Regarding Medical Treatment (Form 395)
• Admission form and discharge summary or certification from a medical records official indicating dates of the accident-related hospitalization and diagnoses (if applicable).

Homemaker Service

• Medical order justifying the need for homemaker services
• Payment receipt with date and cost of the service performed

Orthopedic Equipment

• Invoice with name, equipment or corrective code, and date of service

Disposable Diapers

• Medical certification recommending the use of disposable diapers
• Payment receipt for diaper purchase with date and description of diapers purchased

Dental Injury

• Medical notes from the dentist or detailed invoice for the service provided

Physical Therapy

• Medical notes with date of physical therapy sessions received

**Requisites to claim benefits in policies for losses incurred within six (6) months or less from the effective date of hospitalization supplements for illness, intensive care unit, and disability admission.

• Claim form for hospitalization policy CL-1207-126 (R-0221). completed and signed by the claimant.
• Completed medical certificate, CL-1207-126 (R-0221).
• Authorization to request medical information, signed by the patient over the age of 21 POS-0190-42 (R-0606) or signed by the guardian if the patient is a minor.
• Copy of the patient’s photo ID with signature if of legal age, or the patient’s guardian.
• List of names of physicians and hospitals including telephone numbers, address, and specialty of physicians CL-0207-166 (R-0721)
• Copy of the record of the past 2 years, prior to the issuance of the policy by the physician who started treating you for the claimed condition.
• Detailed medical plan utilization with dates of medical services received, including diagnosis codes, for the 2 years prior to when the policy was issued.

Hospitalization Due to Illness**

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).
• Admission form and discharge summary or certification from a medical records official indicating hospitalization dates and diagnoses

Intensive Care**

• Claim form completed and signed by claimant, CL-1207-126 (R-0221).
• Certification from a medical records official indicating diagnosis(es), date, time of admission and discharge, or intensive care unit admission nursing notes

Total Physical Disability**

• Disability claim form completed in its entirety, including employer and medical certification, CL-0285-10 (R-0221).

• Copy of the record of the physician who certifies the claimed disability, including:
  •  Copy of study results and medication lists
  • Progress Notes for the claimed condition
• If you were treated by the State Insurance Fund Corporation (SIFC), please submit a copy of the following:
  • Medical Certificate (Form 1021)
  • Administrator’s Decision Regarding Medical Treatment (Form 395)
  • Employer Report (Form 373) completed by the employer at the time of the accident