Help to avoid delays. This benefit will only be paid once in a certificate or policy year for each person covered Combined Life Insurance Company of New York Claim Department P.O. Box Scranton, PA Telephone Fax Continuation of Disability Claim Form CLAIMANT STATEMENTPLEASE COMPLETE AND RETURN CITY STATE ZIP CITY STATE ZIP HOSPITAL CONFINEMENT SINCE LAST REPORT HOSPITAL NAME HOSPITAL NAME major sickness or injury keeps you out of work for a week – or months? Products vary by state and are subject