CHUBB Claim Entry

How to File a Fast Track Claim:

Complete the form below in its entirety. All fields are required to submit the form through the fast track process. If we require additional information, a letter will be sent to you requesting the additional information. You should expect to receive a response within 7 - 10 days. After completing your form, you will be given the option to save/print a PDF copy for your records.

Personal Information

First Name	Middle	Last Name

Insured Name

Date of Birth	Member ID
mm/dd/yyyy

Address	Apt. No.

City	State	Zip Code

Phone

Claim Information

1) Exact Nature of Injury or Illness:

a. If Injury, Description of Accident:

b. If condition is Pregnancy, Date of Last Menstrual Period:

mm/dd/yyyy

Physician Contact Information
Full Name of Physician

Address

City	State	Zip Code

Phone

2) Date of Occurrence: mm/dd/yyyy

3) Is condition work related? Yes No

4) Is condition due to an auto accident? Yes No

a. If Yes, Driver License #: State:

b. What type of Vehicle:

5) Hospital Admission Date:	Discharge Date:*
mm/dd/yyyy	mm/dd/yyyy
	*Discharge Date is not included in the benefit calculation

6) Was your stay in:	Semi-Private or Private		ICU		Observation
	# of Days		# of Days		# of Days

7) Name of Hospital:	City:	State:

P.O. Box 4000 ● Collegeville, PA 19426-4000
Phone: 610.293.9229
Fax: 610.293.9299
Toll Free: 888.293.9229