AAU Registered Member Sports Accident Claim Procedure
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1 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. If injured, complete a Claim Form and return it to NAHGA Claim Services via , mail, or fax. Please retain a copy for your records. The Claim Form must be signed by a non-relative coach, witness, Club Administrator or other AAU Organization Official. Notes: If the injured Member is covered by another medical insurance policy, the bills must first be submitted to that Primary Carrier prior to the AAU excess accident insurance plan. The Primary Carrier will issue an Explanation of Benefits (EOB). All itemized bills should be forwarded to NAHGA Claim Services with the corresponding EOB from the Primary Carrier (see above). Each Claim is subject to a $300 deductible (Youth and Adult, Coaches, Volunteers & Officials) The Claim Form must be submitted to NAHGA Claim Services within 90 days of the accident/injury. The first medical treatment must be received within 90 days of the injury. Benefits are payable for covered expenses incurred up to 52 weeks from the date of injury. The maximum benefit offered by this plan is $50,000/injury. Payment will be made directly to the medical provider unless the paid receipt is included with submission. Please submit Claim Form and related documentation to NAHGA Claim Services: PO Box 189 Bridgton, Maine Phone: (800) Fax: (207) [email protected]
2 Please complete this claim form by typing or printing clearly in ink and returning to: NAHGA Claim Services PO BOX 189, Bridgton, ME ( Phone) / (Fax) [email protected] / The following must be completed, dated and signed by an official of the Organization Name of Organization (Policyholder) Amateur Athletic Union of the United States, Inc. Policy Number US Athlete Non-Athlete Male Female Birthdate Youth Adult Coach Official Volunteer Membership I.D. # Name of Team/Club Address of Team/Club Name of Injured Person of Injured Person Part of body injured (include Left or Right) Action Taken Released to Parent Ambulance Transport Refused Care Referred to Hospital/Clinic Own Accord (Adult) Was injury during AAU licensed activity? No Yes Name of Event License # If the injury occurred during a non-licensed event, was the injured party an AB cardholder? No Yes Date the injury was reported to NAHGA Claim Services At the time of injury, was the person involved in an activity under the jurisdiction of the Organization (Policyholder)? No Yes If yes, under whose supervision? Was He / She a witness? No Yes Did the injury occur during: Practice Travel Game Other Date & time of injury Date of 1 st treatment Type of Sport or Activity Describe how and where accident occurred: Page 1 of 5 AAU ACC 0814
3 Please complete this claim form by typing or printing clearly in ink and returning to: NAHGA Claim Services PO BOX 189, Bridgton, ME ( Phone) / (Fax) [email protected] / Nature of injury Print Name of Organization Official Organization Official s Signature Title Phone No PAYMENT WILL BE MADE 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. NEW YORK FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, 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 stated value of the claim for each such violation. AUTHORIZATION: I hereby authorize Fairmont Specialty, U.S. Fire Insurance Company or its representative to inspect or secure copies of medical records, laboratory reports, diagnosis, prognosis, x-rays, and any other data covering this and /or previous conditions, confinements or disabilities. I further acknowledge that this plan is not subject to the federal regulations commonly known as HIPAA. A photo static copy of this authorization and acknowledgment shall be deemed as effective and valid as the original. I ALSO ACKNOWLEDGE THE ATTACHED FRAUD WARNINGS SIGNATURE OF CLAIMANT DATE Or Signature of Parent/Guardian if Claimant is 18 years or younger PO BOX 189, Bridgton, ME ( Phone) / (Fax) [email protected] / Page 2 of 5 AAU ACC 0814
4 THE FOLLOWING MUST BE COMPLETED BY THE INJURED PERSON OR IF THE INJURED PERSON IS UNDER THE AGE OF 18 OR OTHERWISE DEPENDENT BY HIS/HER/ PARENT OR GUARDIAN Member s Name Last Name First Name M.I. SS Number Current Home Address Date of Birth Male Female Membership # Employer Name Employer Address Number and Street City State Zip Code Phone Nor PARENT (OR GUARDIAN) INFORMATION (must be completed if claimant is under 18 years of age) Name of Father or Male Guardian SS Number Current Home Address Employer Name Employer Address Name of Mother or Female Guardian SS Number Current Home Address Employer Name Employer Address Is the claimant covered under any other insurance policy? No Yes Name of Policyholder Individual Group Name of Carrier Carrier s Address Policy No. Name of Policyholder Individual Group Name of Carrier Carrier s Address Policy No. If other insurance exists, all claims must be submitted to the other insurance policies first. A copy of the itemized bills along with the other carrier s corresponding Explanation of Benefits should be submitted for consideration. Page 3 of 5 AAU ACC 0814
5 CLAIM FORM FRAUD STATEMENT FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ARIZONA: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. ALASKA and KENTUCKY: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be prosecuted under state law. CALIFORNIA: For your protection California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. COLORADO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. FLORIDA: WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony. MARYLAND: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NEW HAMPSHIRE: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. NEW JERSEY: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Page 4 of 5 AAU ACC 0814
6 PENNSYLVANIA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. OKLAHOMA: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. TENNESSEE and VIRGINIA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. TEXAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Page 5 of 5 AAU ACC 0814
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