File an Accident or Health Insurance Claim - Payroll Deducted

"Let’s make this easy" are words we take to heart, whether it’s when we’re helping you find the right coverage for your needs, or now, when you need to file a claim. We want to make filing your claim as easy as possible because chances are, you’re looking for our help during a difficult time of your life.

To file a claim for accident and health coverage obtained through Combined Insurance Worksite Solutions, first print or view the Claim Form Instructions below, then simply click on your state of residence from the list below, print out the form and complete it. You can also complete the first page online and print it out; however, you cannot submit the form electronically. Please note, specific sections of the form must be completed by your employer and doctor.

Once complete, mail it to:

Combined Insurance – Worksite Solutions
Claim Department
P.O. Box 6700
Scranton, PA 18505-0700
Phone: 800-544-9382

We appreciate the trust you place in us. Combined Insurance – a good decision


Claim Form Instructions

U.S. Form (All States with the exception of New York)

English / Spanish

New York Form

Authorization to Disclose (All States with the exception of New York)

English / Spanish

Authorization to Disclose (New York Form)


Claims Forms

U.S. Form ( All states with the exception of New York )

English / Spanish

New York Form

English / Spanish

Back to File a Claim

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