Summary of Benefits 1



Similar documents
CRITICAL ILLNESS CLAIMS

INSURANCE EXCLUSIVELY for ABA Members

NOTIFICATION OF INJURY

DISABILITY INCOME/OFFICE OVERHEAD EXPENSE CLAIM INSTRUCTIONS (PLEASE KEEP THIS NOTICE FOR FUTURE REFERENCE)

NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM INSTRUCTIONS

ACCIDENT CLAIM FORM. Daytime telephone No. Patient s full name Date of birth Relationship to policyowner

Loss/Collision Damage Waiver

Leaders Life Insurance Accident Claim Filing Instructions

How To Get A Car Insurance Claim Form

OUTPATIENT PHYSICIAN S TREATMENT CLAIM FORM

NATIONWIDE LIFE INSURANCE COMPANY NATIONAL CASUALTY COMPANY NATIONWIDE SPECIALTY INSURANCE CLAIM FORM

The Accelerated Benefits Option ( ABO )

Disability Benefit Claim Form

INVOICE FOR INDEPENDENT HEALTH CARE PROVIDERS

AAU Registered Member Sports Accident Claim Procedure

ACCIDENT CLAIM FORM. 5. Was patient hospitalized? Yes No NAME OF HOSPITAL CITY STATE

COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS

Accident insurance plain claim form

COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING CLAIMS

Accident Claim Form. (Not to be used if you are filing a disability claim)

You also may have purchased the Hospital Cash Rider and/or the Disability Income Benefit Rider. Refer to your policy for detail information.

POLICYHOLDER / CERTIFICATEHOLDER. Policy Number(s): 1) 2) Social Security Number: Date of Birth: / / Male Female

May 29, Dear Injured Camper or Staff Member and Family:

To file a claim: If you have any questions or need additional assistance, please contact our Claim office at

POLICYHOLDER. Policy No.(s): Waiver of Premium (include life policies) Routine Pregnancy

LIFE INSURANCE DEATH CLAIM

GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE

The forms must be completed by a qualified person and signed with their occupational title as per its respective form.

How 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. 1. Have Parent/Guardian of injured participant or injured adult participant complete and sign appropriate sections of claim form.

CRITICAL ILLNESS CLAIM FORM

Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis.

Accident Claim Filing Instructions

1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code)

Monumental Life Insurance Company

INSTRUCTIONS FOR FILING GROUP VOLUNTARY STD / LTD / WAIVER OF PREMIUM CLAIMS

POLICYHOLDER / CERTIFICATEHOLDER. Policy Number(s): 1) 2) Social Security Number: Date of Birth: / / Male Female

Hospital Confinement/Outpatient Surgery Claim

If your claim is within the policy s contestability period, we may request additional information.

Supplemental Insurance Claim Form Packet

Hospital Indemnity Insurance Claim Form

Disability Claim Form

Transamerica Premier Life Insurance Company

ACCIDENT PLAN CLAIM FORM

PROOF OF LOSS FORM & PAYMENT AUTHORIZATION INSTRUCTIONS

TRIP CANCELLATION OR TRIP INTERRUPTION MEDICAL CLAIM FORM

DISABILITY CLAIM FORM

GROUP LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS BY A THIRD PARTY ADMINISTRATOR

INDIVIDUAL LIFE CLAIM KIT FOR PROCESSING LIFE INSURANCE AND ACCIDENTAL DEATH BENEFITS INSTRUCTIONS FOR FILING A LIFE CLAIM

Humana short-term income protection claim form

NON OWNED & HIRED AUTO

How To Get Insurance Coverage

Policy Owner Address: Street City State ZIP Code

CLAIM FORM. List all dates unemployment benefits are being or have been paid: From: To ; From: To

Middle Name: Suffix: Social Security No.: City: State: Zip Code: City: State: Zip Code: City: State: Zip Code:

ERRORS AND OMISSIONS INSURANCE SUPPLEMENTAL APPLICATION THIRD PARTY ADMINISTRATORS/BENEFIT ADMINISTRATORS ERRORS AND OMISSIONS

United of Omaha Life Insurance Company Group Life Claims Mutual of Omaha Plaza Omaha, NE Toll Free (800) Fax (402)

American General Assurance Company

Death Claim Form Group Life and Accidental Death Insurance

Boston Mutual Life Insurance Company. Group Disability Claim Filing Instructions

Credit Insurance Application

Toll-free: Fax: Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.

AIG Benefit Solutions Underwritten by American General Life Insurance Company*

For use with policies issued by Provident Life and Accident Insurance Company

Accident Claim Filing Instructions

ACCIDENT INSURANCE CLAIM

Name: DOB: / / SSN: Address: Street City State Zip Code

Short Term Disability Claim Statement

ACCIDENT INSURANCE CLAIM

Colonial Life & Accident Insurance Company, Columbia, SC DISABILITY FAX: Telephone:

Advertising agency, marketing and communications application

GUARANTEE TRUST LIFE INSURANCE COMPANY Credit Claim Service Center P.O. Box 1145 Glenview, IL Phone: Fax:

Short-Term Disability Claim Form

Toll-free: Fax: Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.

NON-QUALIFIED ANNUITY DEATH CLAIM ELECTION FORM

What to Expect Whe n Yo u Ha v e A Cl a i m

First Name MI Last. Street Address (P.O. Boxes cannot be accepted) City State Zip. First Name MI Last

Thank you. Should you have any questions, please call us at (800)

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX * SAN ANTONIO, TEXAS

Thank you for this important information. Should you have any questions, please call us at (800)

Portability Option for Group Term Life Insurance

On behalf of our company, we wish to express our sincere condolences on your loss.

NON PROFIT MANAGEMENT LIABILITY APPLICATION

Continue your Aetna life insurance coverage with these options.

Critical Illness. Claimant name Male Female Birth Date Claimant Social Security Number

Toll-free: Fax: Call toll-free Monday through Friday, 8 a.m. to 8 p.m. Eastern Time.

AIG Benefit Solutions Underwritten by

Life Insurance Claimant s Statement

TRUSTMARK INSURANCE COMPANY

Death Claim Form Group Life and Accidental Death Insurance

ERRORS & OMISSIONS RENEWAL APPLICATION

APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 25 FOR INSURANCE COMPANIES

For use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries:

APPLICATION FOR A FINANCIAL INSTITUTION BOND, STANDARD FORM NO. 15 FOR MORTGAGE BANKERS AND FINANCE COMPANIES

Transcription:

Summary of Benefits 1 LifetimeMedicalMaximum $500,000 Deductible $0 CoinsuranceRate PrescriptionDrugs SurgicalTreatment Mental&NervousDisorders TheCompanyPays100%oftheUCC $1,000 Coveredtothemaximumbenefit Treatedasanyothermedicalcondition Pregnancy SportsRelatedInjury AccidentalDeath&Dismemberment EmergencyMedicalEvacuation RepatriationofMortalRemains ComprehensiveSecurityEvacuation PreexistingConditionLimitation TripInterruption 24/7AssistanceServices Coveredasanyothermedicalcondition; conceptionmustoccurwhilepolicyisinforce $3,000 $500,000 $500,000 $250,000 3Monthforprescriptiondrugsonly $2,000 AssistAmerica Thischartservesasasummaryonly.Forafulldescriptionofthecoveragesprovidedpleaserefertothemaster policykeptonfilewithharttravelpartners

HowtoFileaClaim Printandfilloutthebelowclaimform.Besuretocompleteeveryquestionandattach itemizedbills Sendviaemailtoaciclaims@visitaci.com,orviafax1.610.293.9299 YoumayalsomailyourclaimdocumentstoAdministrativeConcepts994OldEagle SchoolRoadSuite1005Wayne,PA19087 Besuretosendinyourclaimwithin90daysofthetreatmentasthisisthedesignated incurralperiod Asyouaretravelingoverseas,theremaybecaseswhereyouwillneedtopayforthe medicalservicesupfrontandsubmityourclaimformforreimbursement.besuretokeep allofyourreceiptsandanyotherdocumentsprovidedtoyoubythefacility. Innonemergencysituations,youshouldcallAssistAmericafirstforreferralstoEnglish speakingfacilitiesinyourarea.inemergencysituations,youorsomeonewhocan representyoushouldcalltheassistancecarrierassoonaspossible.contactinformation willbelistedonyouridcard.wealsorecommendsavingthenumberinyourcellphone (ifapplicable)underemergencycontact,medicalservices. AssistAmericaprovidesafreeapplicationforinsured s.ifapplicableyoushoulddownload theapplicationpriortodeparture.formoreinformation,andtodownloadtheapp, pleasevisithttp://itunes.apple.com/us/app/assistamericamobile/id463805175?mt=8 Inordertocheckthestatusofyourclaim,youmaycallAdministrativeConceptsat1888 2939229,oremailaciclaims@visitaci.com.Forassistancewithclaimsyoucanalsoemail info@intlstudentprotection.comorcontact12126933717. Onlineclaimstatusisavailablethroughhttps://secure.visitaci.com/insuredlogin.asp.Itis recommendedthatyoucreateanaccountpriortodeparture.theinformationneededto enrollwillbeprovidedtoyouonyouridcard.

MAIL TO: Administrative Concepts, Inc. 994 Old Eagle School Road Suite 1005 Wayne, PA 19087-1802 www.visit-aci.com A Insurance Company CLAIM FORM COMPLETE IN DETAIL TO ENSURE PROMPT HANDLING Any person who knowingly knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Group Plan or Program: Name of Insured Individual: Present Address: Home Address: Policyholder Last Name Policy Number First Name Certificate/I.D. Number Middle Initial No. and Street City or Town State Zip Code Country No. and Street City or Town State Zip Code Country Telephone Number: Date of Birth: Male Female (Circle One) If payment is to be made to someone other than the Insured, who is to receive payment? Relationship to insured: Address: Date of Accident or Sickness: Nature of Accident or Sickness: If accident, describe fully how and where accident occurred: If injured in play or practice of sport, indicate what sport: Is the insured covered under any other group plan, health maintenance organization, government plan, or insurance policy? Yes No Insurance Company: Policy Number: Are you covered as a dependent under this policy? Yes No INSURED OR PARENT MUST SIGN BELOW: IFPAYMENT IS TO BE ASSIGNED TO PROVIDER, SIGN Authorization: I hereby authorize release to BELOW: Administrative Concepts, Inc., any and all Authorization: I hereby authorize payment of medical information concerning advice, care or treatment benefits to the medical provider identified on this form, for provided to myself or any of my family which may the service described. be needed to process this claim. Administrative Concepts, Inc. does not share private health information except as required or permitted by law. We are committed to guarding the private information entrusted to us. Insured s Signature: Insured s Signature: Date: Physician or Provider Information Date: (Please Attach Universal 1500 Form or Fill Out In Full Below) Date of First Symptom of Illness Date First Consulted you for Has Patient Ever Had Same or or Injury: this condition: Similar Symptoms? Yes No Diagnosis: History of Illness or Injury: Name of Referring Physician or Other Source: For Services Related to Hospitalization (Give Date) Admitted: Discharged: Name and Address of Facility Where Services Was Laboratory Work Performed Outside Rendered: Your Office? Yes No Lab Charges: Date of Service Place of Service CPT Code Description of Service ICD-9 Charge Will You Accept Assignment?: Yes No Total Charges: Provider s Signature Date Tel. # Print Provider s Name Provider s Address Fax # Tax I.D. # CMI-

PART II Please Print All Information Have you been covered (as an insured or dependent) by any other hospital and/or medical plan for the past 12 months? Yes No If yes, indicate the name and address of the company Effective date of coverage: Expiration date: Policy No. Have you filed a claim with any other insurance company? Yes No I hereby certify that the above information given by me in support of this claim is true and correct. Patient s or Authorized Representative s Signature Date If Authorized Representative, Relationship to Patient or Legal Designation The following section is applicable if you are covered under any other medical insurance plan. Mother s Name Employer s Telephone # Policy No. Employer s Name and Address Name and Address of Insurance Co. Father s Name Employer s Telephone # Policy No. Employer s Name and Address Name and Address of Insurance Co. Spouse s Name Employer s Telephone # Policy No. Employer s Name and Address Name and Address of Insurance Co. The laws of some states require us to furnish you with the following noces: WARNING. Any person who knowingly: Alaska: and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading informaon may be prosecuted under state law. ArizonaArkansas: presents a false or fraudulent claim for payment of a loss or benefit is subject to criminal and civil penales, or specific to AR: presents false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and confinement in prison. California: For your protecon California law requires the following to appear on this form: Any person who knowingly presents 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. Delaware: and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading informaon is guilty of a felony. District of Columbia: It is a crime to provide false or misleading informaon to an insurer for the purpose of defrauding the insurer or any other person. Penales include imprisonment and/or fines. In addion, an insurer may deny insurance benefits if false informaon materially related to a claim was provided by the applicant. Florida: and with intent to injure, defraud, or deceive any insurer, files a statement of claim or applicaon containing any false, incomplete, or misleading informaon is guilty of a felony of the third degree. Idaho and Indiana: and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading informaon (for Idaho) is guilty of and (for Indiana) commits a felony. Kentucky, New York and Pennsylvania: and with intent to defraud any insurance company or other person files an applicaon for insurance, or files a statement of claim, containing any materially false informaon or conceals, for the purpose of misleading, informaon concerning any material fact thereto commits a fraudulent insurance act, which is a crime, specific to PA: subjects such person to criminal and civil penales and specific to NY: shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violaon. Louisiana, New Mexico, Texas and West Virginia: presents a false or fraudulent claim for the payment of a loss (or specific to LA, TX and W VA: who knowingly presents false informaon on an applicaon for insurance) is guilty of a crime and may be subject to fines and confinement in state prison, (or specific to NM: to civil fines and criminal penales.) Maryland: and willfully presents a false or fraudulent claim for payment of loss or benefit or who knowingly and willfully presents false informaon in an applicaon for insurance is guilty of a crime and may be subject to fines and confinement in prison. New Jersey: files a statement of claim containing any false or misleading informaon is subject to criminal and civil penales. Ohio: with intent to defraud or knowing that he is facilitang a fraud against an insurer, submits an applicaon or files a claim containing a false or decepve statement is guilty of insurance fraud. Oklahoma: 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 informaon is guilty of a felony. Oregon: and with intent to defraud any insurance company or other person files an applicaon for insurance or a statement of claim containing any materially false informaon or conceals for the purpose of misleading, informaon concerning any fact material hereto, may be subject to prosecuon for insurance fraud. Puerto Rico: and with the intenon of defrauding presents false informaon in an insurance applicaon, or presents, helps, or causes the presentaon of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon convicon, shall be sanconed for each violaon with the penalty of a fine of not less than five thousand (5,000) dollars and not more than ten thousand (10,000) dollars, or a fixed term of imprisonment for three (3) years, or both penales. If aggravang circumstances are present, the penalty thus established may be increased to a maximum of five (5) years; if extenuang circumstances are present, it may be reduced to a minimum of two (2) years. WARNING: Colorado: It is unlawful to knowingly provide false, incomplete, or misleading facts or informaon to an insurance company for the purpose of defrauding or aempng to defraud the company. Penales 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 informaon to a policyholder or claimant for the purpose of defrauding or aempng to defraud the policyholder or claimant with regard to a selement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Hawaii: Presenng a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both. Maine/Washington: It is a crime to knowingly provide false, incomplete or misleading informaon to an insurance company for the purpose of defrauding the company. Penales may include imprisonment, fines or a denial of insurance benefits. Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. 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 informa- on is subject to prosecuon and punishment for insurance fraud, as provided in RSA 638.20. Tennessee and Virginia : It is a crime to knowingly provide false, incomplete or misleading informaon to an insurer or insurance company for the purpose of defrauding the insurer or insurance company. Penales include imprisonment, fines and denial of insurance benefits.

FrequentlyAskedQuestions IfIhaveamedicalemergency,shouldIcalltheassistancecenternumber,beforeseeking medicaltreatment? Inanemergencysituation,participantsareencouragedtogotothenearestmedicalfacility. Pleasecallthelocal firstresponder inyourlocale(forexample, 911 intheus, 119 in Japan,etc.).YoushouldutilizetheAssistAmericaWebsitetofindandrecordthesenumbers priortoyourdeparture,ordownloadtheassistamericaphoneapplication,previously provided,toaccessthematatouchofabutton. Yourfirstpriorityshouldbetoreceiveproperandnecessarycare.Assoonaspossible,you orsomeonewhocanrepresentyou(tripleader,friend,family,etc.)shouldcontactassist usingthephonenumbersonyouridcardorthephoneapp.theassistancecompanyserves toassistyouinanyway,fromguaranteeingpaymentorprovidingtranslatorservices. Inanonemergencysituation,youareencouragedtocontactAssistAmericaforthenearest Englishspeaking,creditable,facility.ContactingAssistAmericafirstallowstheirteamto workwiththefacilitytoguaranteepayment,expediteclaims,andnegotiatepricingof servicesrendered. Whatiflocalmedicalfacilitiesarenotadequate? Ifyouarehospitalizedinanareawhereadequatemedicalcareisnotavailable,wewill arrangetoevacuateyoutoamedicalfacilitycapableofprovidingtherequiredcare.assist Americaphysicianssuperviseeveryevacuation.Whennecessary,amedicalspecialistor nursewillaccompanyyouduringtheevacuation. WhatifIneedprescriptionmedication? Ifyourequireaprescriptionanditcannotbeobtainedlocally,oryouneedtoreplacelost, stolenordepletedmedication,wewill,subjecttolocalregulations,arrangefortheshipment oftheneededmedication.pleasebeadvisedthatadditionalcostsmayapply. WhatifIamhospitalized? Callyourassistancecenterassoonaspossible.Wewillcommunicatewithyourtreating medicalprovidertodiscussyourcareandtheappropriatestepsforyoursafeandspeedy recovery.ourmedicalteamwillmonitoryourconditionuntilithasbeenresolvedoryou havesafelyreturnedhome.

SolutionsbyAssistAmerica + + + + + + + + + + + + + + 1-800-872-1414 1-609-986-1234 medservices@assistamerica.com

2026 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information