STUDENT ACCIDENT CLAIMS
|
|
- Harvey Chandler
- 8 years ago
- Views:
Transcription
1 STUDENT ACCIDENT CLAIMS When a student (see instructions for the work-study program at the bottom of the page) has an accident on campus the student should be given the attached Student Accident paperwork The injured student is responsible for completing the Student Accident Report and Claim Form All data must be completed and returned to the regional contact responsiblefor handling student accident claims so that claims can be submitted to the insurance carrier Exposure claims (needle sticks and patho~en exposures) are now handled under the Student Accident policy The regional contact will fax the forms to AIG Linda Labrasca of Arthur J Gallagher and Jabari Lewis in Central Office FAX THE STUDENT ACCIDENT PAPERWORK IMMEDIATELY AFTER RECEIVING IT DO NOT WAIT UNTIL BILLS ARE RECEIVED TO REPORT THE CLAIM Any medical bills that are received regarding the student s accident must be forwarded to AIG-Linda Labrasca and Jabari Lewis Bills must be itemized in order to be paid (HCFA UB-92) An itemized bill must contain: patient s name date of service type of service (procedure) nature of condition being treated (diagnosis) provider s name provider s address and provider s tax identification number It is the student s responsibility to obtain an itemized bill 4 A copy of all forms and medical bills submitted must be kept on file by the region submitting the claim The maximum benefit payable under the Student Accident Plan is $3000 Claims above that amount are now the responsibility of the student unless the College has liability in the accident Medical bills above the $3000 limit are no longer transferred and paid under General Liability The Student Accident forms are found in Campus Connect in the Forms section of Infonet under Human Resources and titled "Student Accident Report" The forms are also located in the Student Resources section of Campus Connect under Health & Wellness Students in Work-Study Program *Students involved in work-study programs are considered employees if they are on the job when an accident/illness occurs ~ SEE INSTRUCTIONS ON FILING A WORKER S COMPENSATION CLAIM *Students involved in work-study programs are considered students at all times other than when on the job Contact Information Ivy Tech Office- of the President: Jabari Lewis Phone: Fax: jlewis309@ivytechedu Broker: Arthur J Gallagher Linda Labrasca Phone: Fax: linda_labrasca@aj gcom Claims ($3 000 Maximum) AIG Accident and Health Education Markets Phone: Fax:
2 STUDENT ACCIDENT PAPERWORK The College provides accident insurance with a maximum benefit payable of $3000 for injuries sustained while enrolled and participating in a College course or College-sponsored activity Intramural and recreational sports are excluded from coverage Examples of covered accidents include but are not limited to the following: o Cutting a finger while chopping an onion in culinary arts class ~ Getting a fleck of metal in the eye while welding in auto body repair class ~ Twisting an ankle while lifting a patient in nursing class Exposure to blood borne / airborne pathogen (ex needle stick sustained in clinical)!f the in/urf occurred while conducting duties as a work-study please see the Regional Human Resources department for worker s compensation paperwork If a student is iniured while participatin~ in a College course or College-sponsored activity the followin~ steps MUST be followed: 1 NOTIFY THE INSTRUCTOR OR IVY TECH STAFF IMMEDIATELY 2 Complete the Student Accident Report and attached claim form and submit it to the instructor or the person in charge of handling the regional student accident claims at that location All forms must be complete and si~ned for claims to be considered for payment Student Accident forms~are located on Campus Connect in Student Resources section under Health and Wellness Submit itemized bills to the instructor or person in charge of handling the regional student accident claims The College s insurance carrier requires and only considers eligible expenses from an itemized bill (HCFA 1500 or UB-92) An itemized bill MUST include the following: Patient s name date of service type of service rendered (procedure) nature of condition being treated (diagnosis) provider s name provider s address and provider s tax identification number Samples of the necessary forms are attached STATEMENTS OR PAST DUE BILLS WILL NOT BE ACCEPTED IT IS THE STUDENT S RESPONSIBILITY TO OBTAIN AN ITEMIZED BILL When medical treatment is required as a result of a covered injury the following page may be given to the provider for insurance information Not all claims are eligible under this plan Be prepared to pay for services rendered if the claim is denied by the College s insurance carrier or if the maximum of $3000 has been paid through the plan The student accident plan does not consider sickness as payable under this plan An example of a claim considered sickness is fainting during a clinical Filing a claim does not guarantee acceptance and payment of claim
3 IVY TECH COMMUNITY COLLEGE OF INDIANA STUDENT ACCIDENT REPORT (REPORT CLAIMS IMMEDIA TEL Y- DO NOT WAIT UNTIL BILLS ARE RECEIVED) Region Name Home Address Phone City/State Report Completed Incident Location /Time of Incident Instructor/Supervisor Description of Incident (how it occurred materials/tool being handled and what you were doing) Description of Injury (part of body type of injury) First Aid Given? No Yes Procedure By? EMS Contacted? No Yes Treatment Refused? No Yes Have you paid the provider for services? No Yes **If you have paid the provider(s) directly attach receipt(s) of payment along with the itemized bill(s) If you have not paid the provider(s) payment will be issued directly to the provider(s) Witness INJURIES WHICH OCCUR WHILE PERFORMING DUTIES IN A WORK-STUDY PROGRAM FALL UNDER WORK COMPENSATION PLEASE SEE THE REGIONAL HUMAN RESOURCES DEPARTMENT FOR ALL OTHER STUDENT INJURIES: FILL OUT THE STUDENT ACCIDENT REPORT AND CLAIM FORM AND SUBMIT THE PAPERWORK TO THE REGIONAL CONTACT RESPONSIBLE FOR HANDLING STUDENT ACCIDENT CLAIMS AT THE LOCATION ~CLA1MS RESULTING FROM A MEDICAL CONDITION ARE NOT COVERED UNDER THE ACCIDENT POLICY FILING A CLAIM DOES NOT GUARANTEE ACCEPTANCE AND PAYMENT OF CLAIM CONTACT INFORMATION FOR CLAIMS COMPANY AIG Accident & Health Education Markets PO Box Overland Park KS Ph) Fax) Instructor/Staff Signature Student Signature
4 National Union Fire Insurance Company of Pittsburgh Pa COVERAGE VERIFIED PLEASE PRINT ALL INFORMATION MAIL TO: AIG Educational Markets Mail Center P O Box Overland Park KS SPECIAL NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals for the purpose of misleading information concerning any fact material thereto and any person who knowingly makes or knowingly assists abets solicits or conspires with another to make a false report of the theft destruction damage or conversion of any motor vehicle to a law enforcement agency the department of motor vehicles or an insurance company commits a fraudulent insurance act which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation PART 1 - MUST BE COMPLETED AND SIGNED CLAIM FORM COMPLETE IN DETAIL TO ENSURE PROMPT HANDLING Name of School Policy Number Birth IVY TECH COMMUNITY COLLEGE -ACCIDENT ONLY PLAN CHH Insured s Name Present Address I LAST NAME FIRST NAME MI INSURED S STUDENT ID# SUBSCRIBER ID# PHONE NO AND STREET CITY OR TOWN STATE ZIP + 4 Home Address NO AND STREET CITY OR TOWN STATE ZIP + 4 if claim for dependent give dependent s name relationship to insured DOB Are you covered (as an insured or dependent) by any other hospital and/or medical plan? [] Yes Insured [] Yes Dependent [] No If yes please check one: [] Group [] Individual [] Automobile/Medical If yes also indicate name and policy number of insurance company Name of Insured: Policy #/Group #: ID # Company Have you filed a claim with the above company? [] Yes [] No Send copies of all Explanation of Benefits showing benefits paid and/or benefits denied to the Company at the address above Name and Address of Employer of: [] Insured if employed [] Spouse if insured is married 1 of accident or sickness of first treatment 2 Nature of sickness or injury 3 If injury describe how and when accident occurred and indicate if work related Check One: [] Intramural *4 If injured in practice or play or sport [] Intercollegiate indicate which sport [] Other 5~ Have you previously been troubled with this condition? [] Yes [] No 6 Give name of all other physicians consulted 7 Hospitalized? If so where and what dates Where? From: To: 8 Health Center referral? [] Yes If yes attach referral to claims form [] No If no please explain PAYMENT WILL BE PAID TO THE PROVIDERS OF SERVICE (Hospital Physician and others) UNLESS A PAID RECEIPT OR STATEMENT ACCOMPANIES THE BILL AT THE TIME THE CLAIM IS SUBMITTED * IMPORTANT: ALL INTERCOLLEGIATE SPORTS CLAIMS MUST BE SIGNED BY AN AUTHORIZED ATHLETIC/SCHOOL OFFICIAL I hereby certify that the above injury was sustained while participating in official activities under adequate organizational supervision Signature of College Official Title DATE To any medical care provider medical care facility insurer government-sponsored health plan or employer: I permit (while my claim is pending) the release of any medical information about me to the Company and its representatives The Company s representatives include re-insuring companies and other persons or groups performing business or legal services relating to my claim This applies to all information about the diagnosis treatment or prognosis or any illness or injury I now have or have had in the past The Company will use this information to find out if my claim is eligible A copy of this authorization (one or which will be given to me by the Company upon my request) will be as valid as this one I certify that the above information given by me in support of this claim is true and correct Patient s or Authorized Representative s Signature If Authorized Representative Relationship to Patient STREET CITY STATE Zip Rev (8/09) ITEMIZED BILLS FOR MEDICAL EXPENSES MUST BE ATTACHED NUFIC-GEN
5 PLEASE GIVE THIS SHEET TO THE PROVIDER S OFFICE The patient was injured while fulfilling course requirements for an Ivy Tech class Itemized bills MUST be sent for consideration to the insurance carrier listed below: AIG Accident and Health Education Markets PO Box Overland Park KS Ph) Fax) Student s Name: Policy Number: CHH
STUDENT ACCIDENT CLAIMS
STUDENT ACCIDENT CLAIMS When a student (see instructions for the work-study program at the bottom of the page) has an accident on campus, the student should be given the attached Student Accident paperwork.
More informationNEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW COVER LETTER NAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE* NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE* POLICYHOLDER
More informationNEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE -FAULT BENEFITS NAME AND ADDRESS OF INSURER * NAME, ADDRESS, AND PHONE NUMBER OF INSURER S CLAIMS REPRESENTATIVE* POLICYHOLDER
More informationACCIDENTAL INJURY CLAIM FORM
ACCIDENTAL INJURY CLAIM FORM Failure to complete this form in its entirety may result in a delay in processing this claim. FILING CLAIM FOR (check all that apply): Accidental Injury Only Injury With Disability
More informationAAU Registered Member Sports Accident Claim Procedure
AAU Registered Member Sports Accident Claim Procedure AAU members may be eligible for medical expense benefits for treatment of covered injuries sustained while participating in AAU Licensed activities.
More informationNOTIFICATION OF INJURY
NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. Policies With Excess Coverage Eligible covered expenses will be paid only if they are in excess of other
More informationNOTIFICATION OF INJURY
NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. **Note: The SAI claim form (Parts A & B) should be submitted to Loomis (address on next page) as soon
More information2011-2012 Underwritten By: ACE American Insurance Company Philadelphia, PA 19106
Up to $1,000,000 Student Accident Medical Insurance Protection 2011-2012 Underwritten By: ACE American Insurance Company Philadelphia, PA 19106 (Form RI) Important Notice: The Plan does not provide benefits
More informationMonumental Life Insurance Company
Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage
More informationMANHATTAN ORTHOPEDIC & SPORTS MEDICINE GROUP, PC
MANHATTAN ORTHOPEDIC & SPORTS MEDICINE GROUP, PC Edmond Cleeman, M.D. Craig DuShey, M.D. Marvin S. Gilbert, M.D. Richard S. Gilbert, M.D. Mark J. Klion, M.D. Vikas Varma, M.D. 1065 Park Avenue New York,
More information1. FULL NAME (LAST, FIRST) SOCIAL SECURITY NUMBER: 2. ADDRESS CITY STATE ZIP CODE PHONE NUMBER:
THE UNITED STATES LIFE Insurance Company An American General Company 3600 Route 66 - PO Box 1580 - Neptune NJ 07754 1580-732 922 7000 APPLICATION FOR LONG TERM DISABILITY BENEFITS (To Avoid Delay Please
More informationDISABILITY CLAIM FORM
ACE American Insurance Company PROOF OF LOSS Mail to: ACE American Insurance Company Name of Group: UNIVERSITY OF CALIFORNIA P.O. Box 15417 Wilmington, DE 19850 800-336-0627 or 302-476-6194 Policy Number:
More informationDomestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005
Domestic Accident & Health Division 80 Pine Street, 13 th Floor New York, NY 10005 Welcome to the AIG Companies family of customers. We appreciate that you had a choice when placing your insurance and
More informationTransamerica Premier Life Insurance Company
Insurance Claim Filing Instructions PROOF OF LOSS CONSISTS OF THE FOLLOWING: 1. A completed and signed Claim form and Attending Physician s Statement. 2. For Hospital/Intensive Care/Hospital Services Coverage
More informationCatlin Underwriting Agency, U.S., Inc. 1330 Post Oak Blvd. Ste 2325 Houston, TX 77056
Catlin Underwriting Agency, U.S., Inc. 1330 Post Oak Blvd. Ste 2325 Houston, TX 77056 CORPORATE EMERGENCY ROOM / AMBULATORY CARE MEDICAL PROFESSIONAL UNDERWRITING QUESTIONNAIRE AND APPLICATION FOR PROFESSIONAL
More informationNOTIFICATION OF INJURY
NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. Policies With Excess Coverage Eligible covered expenses will be paid only if they are in excess of other
More informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM
NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF PAYMENTS FROM
More informationACCIDENT INSURANCE CLAIM
ACCIDENT INSURANCE CLAIM ReliaStar Life Insurance Company A member of the ING family of companies Administered by: Key Benefit Administrators, Inc., P.O. Box 1238 Fort Mill, SC 29716 Phone: 866-225-8704,
More informationLife Short Term Disability
a lifetime of commitment c o m p a n i o n b u s i n e s s plan f o r groups of 2 t h r o u g h 9 e m p l o y e e s www.companionlife.com Life Short Term Disability Approximately 30 percent of all people
More informationAUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL)
Surplus Call 800-342-5706 Insurance Fax 800-578-7758 www.surplusins.com Email quotes: submit@surplusins.com Brokers Agency Inc. P O Box 749, South Bend IN 46624-0749 AUTOMOBILE APPLICATION FOR INSURANCE
More informationRoush Insurance Services, Inc.
Roush Insurance Services, Inc. PO Box 1060 Noblesville, IN 46061-1060 Phone (800) 752-8402 Fax (317) 776-6891 Email: quote@roushins.com www.roushins.com AUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING
More informationAccident Claim Statement
Accident Claim Statement For your protection, the following disclosures are required by state law and are based on the state where you live: If you live in the states of Alaska or Oregon, the following
More informationThe forms must be completed by a qualified person and signed with their occupational title as per its respective form.
Your ability to work and generate income is your greatest asset. If a disability ever left you unable to work, a combination of increased expenses and loss of income could create financial difficulties.
More informationCOMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING CLAIMS
COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING CLAIMS GETTING STARTED Follow the Claimant Instructions below to complete the form. Upon completion of the first page you can: Mail OR fax
More informationHow To File a Claim. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form.
How To File a Claim The Claim Form (M18979) is prepared by the Girl Scout volunteer or another authorized person, usually one who was at the scene of the accident and familiar with the circumstances. Volunteer
More informationHow To File a Claim. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form.
How To File a Claim The Claim Form (M18979) is prepared by the Girl Scout volunteer or another authorized person, usually one who was at the scene of the accident and familiar with the circumstances. Volunteer
More informationACCIDENT INSURANCE CLAIM
ACCIDENT INSURANCE CLAIM Employee Benefits ReliaStar Life Insurance Company A member of the ING family of companies Administered by: Your future. Made easier. SM Key Benefit Administrators, Inc., PO Box
More informationAMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502
P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 DISABILITY CLAIM FORM INSTRUCTIONS Enclosed is a claim form required in order to process disability payments on your loan. It is important that all questions
More informationEMPLOYER S STATEMENT
Liberty Life Assurance Company of Boston TO BE COMPLETED BY EMPLOYER Employee s Name, Address & Phone No. EMPLOYER S STATEMENT Mail to: Group Market Disability Claims Liberty Life Assurance Company of
More informationAct Now! GIVE YOUR FAMILY PEAK PROTECTION. Group Long Term Disability Insurance Conversion Plan Enrollment Kit
Act Now! You must apply within 60 days of termination GIVE YOUR FAMILY PEAK PROTECTION Group Long Term Disability Insurance Conversion Plan Enrollment Kit Customer Service Center 888-262-6873 Monday through
More informationProperty/Casualty Insurance Renewal Survey Multi-State
Property/Casualty Insurance Renewal Survey Multi-State P.O. Box 5670 Cortland, New York 13045 Phone (800) 822-3747 Fax: (607) 758-9028 Email: applications@ mcneilandcompany.com GENERAL INFORMATION Date
More informationPOLICYHOLDER / CERTIFICATEHOLDER. Policy Number(s): 1) 2) Social Security Number: Date of Birth: / / Male Female
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationSummary of Benefits 1
Summary of Benefits 1 LifetimeMedicalMaximum $500,000 Deductible $0 CoinsuranceRate PrescriptionDrugs SurgicalTreatment Mental&NervousDisorders TheCompanyPays100%oftheUCC $1,000 Coveredtothemaximumbenefit
More informationLife Insurance Claim Requirements
Life, AD&D, Living/Accelerated Benefit Claim Form Instructions Section A: Section B: Section C: Section D: Section E: Section F: General Information to be completed by the employer s authorized representative.
More informationFirst Name MI Last. Street Address (P.O. Boxes cannot be accepted) City State Zip. First Name MI Last
Accident Claim Form Instructions for Filing a Claim LIFESECURE INSURANCE COMPANY ADMINISTRATIVE OFFICE ATTN: Claims Department PO Box 13490, Pensacola, FL 32591-3490 1-888-575-8246 Please have all sections
More informationNEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW COVER LETTER NAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE* NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE* POLICYHOLDER
More informationAUTOMOBILE APPLICATION FOR INSURANCE FOR NON-TRUCKING USE (BOBTAIL)
National Casualty Company Home Office: Madison, Wisconsin Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza
More informationNATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS
NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS THIS CLAIM CANNOT BE PROCESSED WITHOUT ALL OF THE BELOW INFORMATION AND STATEMENTS OF
More informationDisability Claim Form
Disability Claim Form Fax to: 1.866.887.6644 From: Number of pages: Please be sure to send the following Information: A fully completed physician s section, A fully completed employer s section, A signed
More informationHow To Get A Car Insurance Claim Form
ACCIDENTAL INJURY / SICKNESS CLAIM FORM Servicing is provided for the following companies: Conseco Insurance Company Conseco Health Insurance Company Conseco Life Insurance Company Washington National
More informationGreenwich Insurance Company REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE RENEWAL APPLICATION
REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE RENEWAL APPLICATION te: Failure to submit a completed application in a timely manner could jeopardize your prior acts coverage. Named Insured: Policy.:
More informationTo file a claim: If you have any questions or need additional assistance, please contact our Claim office at 1-800-811-2696.
The Accident Expense Plus policy is a financial tool that helps cover high deductibles, co-pays and other expenses not covered by your primary major medical plan. This supplemental plan reimburses you
More informationDisability Benefit Claim Form
Transamerica Worksite Marketing P.O. Box 8043 Little Rock, AR 72203-8043 Phone: 800-251-7254 (7:00 a.m. 5:00 p.m. CST) Fax: 866-586-6528 Disability Benefit Claim Form Instructions to submit claim 1) The
More informationMay 29, 2015. Dear Injured Camper or Staff Member and Family:
May 29, 2015 Dear Injured Camper or Staff Member and Family: We are sorry to hear that you sustained an accidental injury or an unexpected illness at one of our camps. The following pages contain the claim
More informationYou also may have purchased the Hospital Cash Rider and/or the Disability Income Benefit Rider. Refer to your policy for detail information.
Your Emergency Care policy is supplemental insurance to help cover the additional expenses associated with an accidental injury. An Accident is defined as an unforeseen occurrence of an event, which results
More informationERRORS & OMISSIONS RENEWAL APPLICATION
ERRORS & OMISSIONS RENEWAL APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE
More informationWorkers Compensation
Workers Compensation All work-related injuries or illnesses must be reported. If the injury is an emergency, arrange for appropriate medical treatment. The employee has the right to select his or her own
More informationACCIDENT CLAIM FORM. Daytime telephone No. Patient s full name Date of birth Relationship to policyowner
BOSTON MUTUAL LIFE INSURANCE COMPANY HOME OFFICE: 120 Royall Street Canton, MA 02021 ADMINISTERED BY: PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY PO Box 34952 Omaha, NE 68134-9832 TEL 1-888-453-5120 FAX
More informationAccident Claim Form. (Not to be used if you are filing a disability claim)
Fax to: Claims 1.800.880.9325 From: No#of pages: Or Mail to: P.O. Box 100195 Columbia SC 29202-3195 Accident Claim Form (Not to be used if you are filing a disability claim) Please be sure to send the
More informationAccident Claim Filing Instructions
Accident Claim Filing Instructions The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this authorization as We or Humana. Life, Specified
More informationPOLICYHOLDER. 4. Date of Birth: / / Age: Social Security Number: Male Female MO/DAY/YR. Policy No.(s):
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center
More informationSI 2047-643383 1 of 6 (12/04)
Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save
More informationPOLICYHOLDER. Policy No.(s): Waiver of Premium (include life policies) Routine Pregnancy
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationHow To Get Insurance Coverage
RLP- Renter's Liability Protection SLI - Supplemental Liability Insurance APPLICANT'S SECTION: 1. Business name (s) of applicant (list full entity name, dba's, etc., and state of incorporation, if applicable)
More informationColonial Life & Accident Insurance Company, Columbia, SC DISABILITY FAX: 1-800-880-9325 Telephone: 1-800-325-4368.
Disability Claim FAX this direction FAX this form: 1-800-880-9325 Or mail: P.O. Box 100195, Columbia, SC 29202 From: Number of pages: Optional Service Release Agreement Please indicate below for optional
More informationRENEWAL Application for Business and Management (BAM) Indemnity Insurance
rthwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com
More informationERRORS & OMISSIONS INSURANCE APPLICATION
ERRORS & OMISSIONS INSURANCE APPLICATION UNDERWRITING OFFICE: 14643 Dallas Parkway Suite 770 Dallas, TX 75254 THIS IS AN APPLICATION FOR A CLAIMS MADE AND REPORTED POLICY. THIS POLICY APPLIES ONLY TO THOSE
More informationSupplemental Insurance Claim Form Packet
Supplemental Insurance Claim Form Packet The Mid-West National Life Insurance Company of Tennessee strives to provide easy and accurate claim filing information to our Insured. This packet contains all
More informationThe Long Term Disability Benefits application includes claim forms and an Authorization.
Disability Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for Long Term Disability benefits. Every space on these forms should be filled
More informationAccident insurance plain claim form
The Lincoln National Life Insurance Company PO Box 82087, Lincoln, NE 68501-2087 toll free (800) 423-2765 Fax (877) 843-3950 www.lincolnfinancial.com Accident insurance plain claim form Policy Holder Information
More informationHospital Confinement/Outpatient Surgery Claim
FAX this direction If your name has changed, attach a copy of your driver s license or other legal documentation. Hospital Confinement/Outpatient Surgery Claim FAX this form: 1-800-880-9325 Or mail: P.O.
More informationCOMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS
COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS If you are filing for the medical expense benefit only under your accident policy, a claim form may not be needed
More informationCHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE INSURANCE
370 West Park Avenue, P. O. Box 9004, Long Beach, NY 11561-9004 Tel: (516) 431-4441 Fax:(516) 889-9872 CHILDREN TRANSPORTATION PROVIDERS APPLICATION AND SURVEY FOR AUTOMOBILE LIABILITY AND PHYSICAL DAMAGE
More information*87503* Group Insurance. Group Life Claim for Total Disability Benefits Employee Statement
Group Life Claim for Total Disability Benefits Employee Statement Instructions to file a Claim for Group Life Insurance Coverage for Total Disability 1. Complete all sections of the Employee Statement
More informationOUTPATIENT PHYSICIAN S TREATMENT CLAIM FORM
OUTPATIENT PHYSICIAN S TREATMENT CLAIM FORM If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer
More informationInstructions for Reporting an Injury
Instructions for Reporting an Injury 1. Injured participant or parents of injured participant (if a minor) will complete the USA RUGBY INCIDENT REPORT. 2. Once INCIDENT REPORT is complete email report
More informationYour Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis.
Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis. The Critical Care Benefit is a one time lump sum payment.
More informationACCIDENT CLAIM FORM. 5. Was patient hospitalized? Yes No NAME OF HOSPITAL CITY STATE
ACCIDENT CLAIM FORM INSTRUCTIONS: 1. Please make sure all questions are complete on this form. 2. If we request an authorization form from you, please complete, sign and date the authorization form we
More informationIf your claim is within the policy s contestability period, we may request additional information.
Your Cancer Care policy is a limited benefit plan that is designed to supplement the cost of medical procedures and expenses due to the treatment of Cancer. There are three plan options available. Cancer
More informationApplication For Business and Management (BAM) Indemnity Insurance Non-Profit Organizations
Northwest Professional Center 227 US Hwy 206, Suite 302 Flanders, NJ 07836-9174 Tel: (973) 252-5141 / (800) 689-2550 Fax: (973) 252-5146 / (800) 689-2839 www.eriskservices.com email: application@eriskservices.com
More informationCOMMERCIAL AUTO APPLICATION
COMMERCIAL AUTO APPLICATION Dependent upon state authority, you are applying for insurance coverage provided by and underwritten by one of the following insurance companies of ARGO GROUP US: ARGONAUT-MIDWEST
More informationINSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding our determination of your claim, or if you would like to appeal any determination, please contact our Customer Care Center at 1-800-348-4489
More informationPROFESSIONAL GROUP PLANS, INC.
PROFESSIONAL GROUP PLANS, INC. Specializing in Employee Benefits Horizon Healthcare of New York New Business Submission Checklist Small Group Sold Case Checklist Employer Application Copy of Sold Proposal
More informationMAIL TO: AIG Benefit Solutions P.O. Box M, Beattyville, KY 41311 FAX: (888) 598-0575
Application for Disability Benefits PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF YOUR CLAIM. INSTRUCTIONS: INSURED: COMPLETE PART I, SIGN AND THE AUTHORIZATION FOR RELEASE
More information1. Name of applicant Last First Middle. Home Phone FAX number E-mail address. Complete title of your medical professional designation
2 Park Avenue 8 British American Blvd. New York, NY 10016 Latham, NY 12110 Tel: 212-576-9800 Tel: 518-786-2700 2 Clinton Square 90 Merrick Avenue Syracuse, NY 13202 East Meadow, NY 11554 Tel: 315-428-1188
More informationMartial Arts General Liability Application
Markel Insurance Company P.O. Box 2009, Glen Allen, VA 23058-2009 Telephone: (800) 866-7403 Fax: (804) 273-6144 Email applications to: sportsandfitness@markelcorp.com Website: martialartsinsurance.com
More informationAddress: SINGLE MARRIED OTHER ADDRESS STREET & NUMBER CITY STATE AND ZIP CODE PHONE NUMBER POLICYHOLDER
American Family Life Assurance Company of Columbus (AFLAC) ATTN: CLAIMS DEPT., WORLDWIDE HEADQUARTERS: 1932 WYNNTON ROAD, COLUMBUS, GA 31999-7251 FOR INFORMATION, CALL TOLL-FREE 1-800-99-AFLAC (1-800-992-3522)
More informationAMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502
P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 CREDIT LIFE CLAIM FORM INSTRUCTIONS Enclosed is a form required to process a claim for credit life benefits. It is important that all questions be fully
More informationFirst Name MI Last Name. City State ZIP Code. Male Female Unmarried Married Divorced Widowed. Spouse s Date of Birth (MM DD YYYY)
Group Disability Insurance Employee Statement The Prudential Insurance Company of America Disability Management Services PO Box 13480, Philadelphia, PA 19176 Tel: 800-842-1718 Fax: 877-889-4885 wwwprudentialcom/mybenefits
More informationThe Long Term Disability Benefits application includes claim forms and an Authorization.
Long Term Disability Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for Long Term Disability benefits. Every space on these forms should
More informationPENNSYLVANIA Assurant Health Individual Medical Metallic Plans Enrollment Packet
Client Tip Sheet PENNSYLVANIA Assurant Health Individual Medical Metallic Plans Enrollment Packet Thank you for applying for an Assurant Health Individual Medical Metallic plan. Please review the product
More informationPOLICYHOLDER / CERTIFICATEHOLDER. Policy Number(s): 1) 2) Social Security Number: Date of Birth: / / Male Female
CLAIM FORM AND INSTRUCTIONS If you have any questions regarding benefits available, or how to file your claim, or if you would like to appeal any determination, please contact our Customer Care Center
More informationGroup Term Life Insurance Portability Election Form
Group Term Life Insurance Portability Election Form You may apply for Group Term Life Insurance coverage under Prudential s portability option. This option may be available to you and your covered dependents
More informationGreenwich Insurance Company
REAL ESTATE PROFESSIONAL ERRORS AND OMISSIONS INSURANCE APPLICATION tice: This is an application for a policy that contains Claims-made liability protection. Coverage for prior acts and claims made after
More informationSTATEMENT OF RECOVERY OR RETURN TO WORK
STATEMENT OF RECOVERY OR RETURN TO WORK DISABILITY INCOME CLAIM INSTRUCTIONS (PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE) Please answer all questions on the Member Statement
More informationTime to choose. Your benefits from Sun Life Financial. Employee Benefits. The Research Foundation for the State University of New York
Time to choose Your benefits from Sun Life Financial The Research Foundation for the State University of New York Employee Benefits It s time for you to take control of your benefits! Welcome to Sun Life!
More informationPolicy Owner Address: Street City State ZIP Code
TRUSTMARK INSURANCE COMPANY PO BOX 7937 LAKE FOREST IL 60045-7937 1-800-918-8877 FAX 1-847-615-3128 www.trustmarkins.com/customersolutions ACCIDENT CLAIM FORM This form must be completed by the attending
More informationSICKNESS CLAIM FORM. Failure to complete this form in its entirety may result in a delay in processing this claim.
SICKNESS CLAIM FORM FILING CLAIM FOR (check all that apply): Sickness Pregnancy Hospitalization Deceased - Date Deceased: / / Cancer Failure to complete this form in its entirety may result in a delay
More informationWhat to Expect Whe n Yo u Ha v e A Cl a i m
10. Can I fax my claim form? Yes, we can accept faxes at 508-853-2867; we also ask that the original be sent via mail. Our fax number appears in the upper left-hand corner of our Claim Forms for your convenience.
More informationSMALL EMPLOYER GROUP APPLICATION INSTRUCTIONS
SMALL EMPLOYER GROUP APPLICATION INSTRUCTIONS This form should be completed with the assistance of your authorized Broker or Horizon Healthcare of New York Sales Representative. Please be sure that all
More informationFor use with policies issued by Provident Life and Accident Insurance Company
For use with policies issued by Please mail or fax this form to: The Benefits Center P.O. Box 100158, Columbia, SC 29202-3158 This form must be completed by the Attending Physician and the Employee, and
More informationGroup Term Life Insurance Continuation Form
Group Term Life Insurance Continuation Form Employees must be actively at work at the time of employment termination or retirement in order to be eligible for the continuation plan. Coverage terminates
More informationMiddle Name: Suffix: Social Security No.: City: State: Zip Code: City: State: Zip Code: City: State: Zip Code:
Please print clearly. Form may be returned for unanswered questions. 1. CLAIMANT Last Name: Middle Name: Suffix: Social Security No.: Patient No.: Birthdate: Gender: Male Female Height: Weight: Spouse/Domestic
More informationGenerali Worldwide Health Insurance Dental Claim Form
Generali Worldwide Health Insurance Dental Claim Form Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate. INSTRUCTIONS FOR FILING A DENTAL CLAIM 1. Please type or print
More informationThe Accelerated Benefits Option ( ABO )
The Accelerated Benefits Option ( ABO ) Metropolitan Life Insurance Company Group Life Claims Telephone Number: 1-800-638-6420 Please read the following important information before completing the attached
More informationACCIDENTAL INJURY CLAIM FORM
ACCIDENTAL INJURY CLAIM FORM Failure to complete this form in its entirety may result in a delay in processing this claim. FILING CLAIM FOR (check all that apply): Accidental Injury Only Injury With Disability
More informationState of Florida Group Long Term Disability Claim Form
State of Florida Account Participating Agencies and Departments Payroll Deduction Code 0300 Mail To: Cigna P.O. Box 16491 Pittsburgh, PA 15242-0791 1-800-238-2125 Toll Free Claims administered by Cigna
More informationNEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE -FAULT INSURANCE LAW COVER LETTER NAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE* NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE* POLICYHOLDER
More informationFor use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries:
CLAIM FOR INCOME PROTECTION BENEFITS The Benefits Center, P.O. Box 9500, Phone: 800.858.6843 Fax: 800.447.2498 For use with policies issued by the following UnumProvident Corporation [ UnumProvident ]
More informationBasic Procedures for Submitting a Youth Soccer Accident Claim Form
6300 Ridglea Place, Suite 614 Fort Worth, Texas 76116 (817) 738-6100 λ Fax: (817) 738-2993 (NOTE: Claim Form must be fully completed and signed.) Basic Procedures for Submitting a Youth Soccer Accident
More information