Fillable 1029- ParticipantAccidentClaimForm 3-07 1029 K&K_DRAFT

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1029- ParticipantAccidentClaimForm 3-07 1029 K&K_DRAFT

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(NOTE To the Participant/Parent/Guardian: Report and Claim Form will be returned if not fully completed and signed.)
Basic Procedures for Submitting the Incident Report and
Participant Accident Insurance Claim Form
1. The insurance coordinator, coach or league representative will complete
the incident report (front). If the policy provides accident medical
coverage and the injured party was an event participant, the form should
be given to the participant or parents to complete the participant accident
medical insurance claim form (Part II).
2. The participant or participant’s parents/guardian will complete the form,
detach it from the instruction page, and forward it to K&K Insurance
Group, Inc.
3. IF CLAIM INVOLVES INJURY TO A SPECTATOR OR PROPERTY DAMAGE,
ONLY THE INCIDENT REPORT NEED BE COMPLETED.
To the Participant/Parent/Guardian:
Attach current itemized physician, hospital, or other provider's bills for
accident medical expenses being claimed as well as the primary carrier's
Explanation of Benefits showing their payments and denials. These bills
must show the patient's name, condition (diagnosis), type of treatment
given, date the expense was incurred and the charges made.
MAIL TO:
K&K INSURANCE GROUP, INC.
Claims Department
P.O. Box 2338
Fort Wayne, Indiana 46801-2338
(800) 237-2917
PARTICIPANT ACCIDENT
INSURANCE CLAIM FORM
ACCIDENT MEDICAL INSURANCE CLAIM FORM
IT IS IMPORTANT THAT ALL INFORMATION REQUESTED ON THIS
CLAIM FORM BE FURNISHED.
OMISSION OF VITAL INFORMATION WILL CAUSE DELAY IN CLAIM PROCESSING.
TO BE COMPLETED BY INJURED PERSON OR PARENT
PART II
COVERAGE UNDER THE POLICY IS EXCESS OVER ALL OTHER HEALTH & ACCIDENT INSURANCE AVAILABLE. YOUR CLAIM SHOULD BE
SUBMITTED TO THE INSURANCE COMPANY PROVIDING COVERAGE TO YOU THROUGH YOUR OWN OR YOUR PARENT'S PERSONAL
HEALTH PLAN, YOUR EMPLOYER OR GOVERNMENTAL HEALTH PLAN. AFTER OTHER INSURANCE BENEFITS HAVE BEEN SUBMITTED,
YOU SHOULD FORWARD A COPY OF THE OTHER INSURANCE COMPANY'S EXPLANATION OF BENEFITS AND THE CORRESPONDING
ITEMIZED MEDICAL STATEMENTS. IF YOUR INSURANCE COMPANY DENIES BENEFITS, SEND A COPY OF THEIR DENIAL. IF THERE IS
NO OTHER INSURANCE, THIS POLICY WILL ACT AS PRIMARY INSURANCE. NOTE: COVERAGE MAY ALSO INCLUDE A POLICY
DEDUCTIBLE.
WE WILL NOT PROCESS YOUR CLAIM WITHOUT EMPLOYER INFORMATION. IT IS IMPERATIVE THAT WE RECEIVE ALL DATA REQUESTED.
TIMELY RECEIPT OF REQUESTED INFORMATION WILL HELP EXPEDITE PROCESSING OF YOUR CLAIM
I WAIVE ANY PROVISION OF LAW TO THE CONTRARY AND HEREBY AUTHORIZE K&K OR ITS REPRESENTATIVES TO FURNISH TO ANY
HOSPITAL, PHYSICIAN OR OTHER PERSON WHO HAS ATTENDED ME, AND MY INSURANCE CARRIER, ANY AND ALL INFORMATION WITH
RESPECT TO THE ACCIDENTAL INJURY FOR WHICH I AM CLAIMING INSURANCE BENEFITS.
I WAIVE ANY PROVISION OF LAW TO THE CONTRARY AND HEREBY AUTHORIZE ANY HOSPITAL, PHYSICIAN OR OTHER PERSON WHO
HAS ATTENDED ME, AND MY INSURANCE CARRIER OR EMPLOYER, TO FURNISH TO K&K OR ITS REPRESENTATIVES ANY AND ALL
INFORMATION WITH RESPECT TO ANY SICKNESS OR INJURY, MEDICAL HISTORY, CONSULTATION, PRESCRIPTIONS, OR TREATMENT,
AND COPIES OF ALL HOSPITAL, MEDICAL, OR INSURANCE RECORDS INCLUDING, BUT NOT LIMITED TO, INFORMATION REGARDING
OTHER INSURANCE COVERAGES. I AGREE THAT A PHOTOCOPY OF THIS AUTHORIZATION SHALL BE CONSIDERED AS EFFECTIVE AS
THE ORIGINAL.
I UNDERSTAND THIS AUTHORIZATION IS NECESSARY TO FACILITATE THE OBTAINING AND PROVIDING OF INFORMATION NEEDED TO
QUICKLY PROCESS MY CLAIM.
SIGNED: DATE:
Please Note: If injured person is a minor, signature must be of parent or legal guardian.
1029 3/07
INJURED PERSON:
FATHER’S NAME (if injured is a minor)
EMPLOYER NAME:
EMPLOYER ADDRESS:
CITY: STATE: ZIP:
PHONE: ( )
GROUP INSURANCE COMPANY:
POLICY NUMBER:
INSURANCE COMPANY ADDRESS:
CITY: STATE: ZIP:
SOCIAL SECURITY NUMBER:
SIGNATURE:
SPOUSE’S NAME (if applicable):
MOTHER’S NAME (if injured is a minor)
EMPLOYER NAME:
EMPLOYER ADDRESS:
CITY: STATE: ZIP:
PHONE: ( )
GROUP INSURANCE COMPANY:
POLICY NUMBER:
INSURANCE COMPANY ADDRESS:
CITY: STATE: ZIP:
SOCIAL SECURITY NUMBER:
SIGNATURE:
1712 Magnavox Way P.O. Box 2338
Fort Wayne, Indiana 46801
(800) 237-2917 Fax (260) 459-5910
http://www.kandkinsurance.com
K&K
INCIDENT
REPORT
(PLEASE PRINT)
NATURE BODILY INJURY PROPERTY DAMAGE OTHER:
TIME & PLACE DATE: TIME: AM PM
OF INCIDENT EVENT:
SPORT:
SANCTIONED BY:
LOCATION:
HAPPENED TO NAME:
AGE: SEX: Male Female PHONE: ( )
ADDRESS:
CITY: STATE: ZIP:
FUNCTION AS: PARTICIPANT VOLUNTEER SPECTATOR BYSTANDER OFFICIAL
OTHER:
APPARENT BODY PART:
INJURY CONDITION: (Laceration, Concussion, Sprain, Fracture, Etc.):
OR DAMAGE ON-SITE CARE ONLY, BY (PHYSICIAN) (EMT) (TRAINER) OTHER:
AMBULANCE, TAKEN TO: CITY:
FATALITY
OCCASION WHAT WAS THE SITUATION AND EXACT LOCATION AT THE TIME OF THE INCIDENT?
INCIDENT DESCRIBE WHAT HAPPENED:
DESCRIPTION
WITNESSES NAME: NAME:
ADDRESS: ADDRESS:
PHONE: PHONE: ( )
INSURED NAME OF INSURED:
POLICY#:
CLUB NAME`: CITY/STATE:
COACH/OFFICIAL/ NAME:
PHONE: ( )
TEAM OR LEAGUE TITLE: ORGANIZATION:
REPRESENTATIVE SIGNATURE: DATE:
COMPLETE ALL SECTIONS AND FAX TO (260) 459-5910 OR MAIL IMMEDIATELY TO:
K&K INSURANCE GROUP, INC., P.O. BOX 2338, FORT WAYNE, IN 46801-2338
THIS FORM MUST INCLUDE THE INSURED NAME, POLICY NUMBER, AND SIGNATURE OF THE INSURED/REPRESENTATIVE
BEFORE RETURNING OR PROCESSING MAY BE DELAYED
1029 3/07
INSTRUCTIONS FOR COMPLETING THE ACCIDENT INSURANCE FORM
TO THE INJURED PERSON/PARENT /GUARDIAN
To the injured person/parent/guardian:
Complete part II of this claim form. Attach current itemized physician, hospital, or other provider's bills for accident medical expenses as well
as the primary carrier's explanation of benefit showing their payment and denial. These bills must show the patient's name, condition (diag-
nosis), type of treatment given, date the expense was incurred, and the charges made. Return this form to K&K Insurance Group, Inc. Please
note: Claim forms will be returned if not fully completed and signed. Omission of vital information will cause a delay in claim processing.
Dear Participant: If you have an appointment with a doctor as the result of a sport related injury, please show this document to
the doctor's insurance secretary. You should be identified as a member of the following preferred provider networks and/or
their affiliates.
Dear Doctor or Provider: This document indicates that this patient is a participant in the following preferred provider networks
and/or their affiliates:
1029 3/07
Applicable in 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.
Applicable in Arkansas, Delaware, District of Columbia, Kentucky,
Louisiana, Maine, Michigan, New Jersey, New Mexico, New York,
North Dakota, Pennsylvania, South Dakota, Tennessee, Texas,
Virginia, Washington and West Virginia
Any person who knowingly and with intent to defraud any insurance compa-
ny or another person, files a 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, subject to criminal prosecution and [NY: substantial] civil
penalties. In DC, LA, ME, TN, VA and WA, insurance benefits may also be
denied.
Applicable in 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
payment of a loss is guilty of a crime and may be subject to fines and con-
finement in state prison.
Applicable in 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 policy holder or claimant for the pur-
pose of defrauding or attempting to defraud the policy holder 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.
Applicable in Florida and Idaho
Any person who knowingly and with the intent to injure, defraud, or deceive
any insurance company files a statement of claim containing any false,
incomplete or misleading information is guilty of a felony.*
* In Florida - Third Degree Felony
Applicable in Hawaii
For your protection, Hawaii law requires you to be informed that presenting
a fraudulent claim for payment of a loss or benefit is a crime punishable by
fines or imprisonment, or both.
Applicable in Indiana
A person who knowingly and with intent to defraud an insurer files a state-
ment of claim containing any false, incomplete, or misleading information
commits a felony.
Applicable in Minnesota
A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
Applicable in Nevada
Pursuant to NRS 686A.291, any person who knowingly and willfully files a
statement of claim that contains any false, incomplete or misleading infor-
mation concerning a material fact is guilty of a felony.
Applicable in New Hampshire
Any person who, with purpose to injure, defraud or deceive any insurance
company, files a statement of claim containing any false, incomplete or mis-
leading information is subject to prosecution and punishment for insurance
fraud, as provided in RSA 638:20.
Applicable in Ohio
Any person who, with intent to defraud or knowing that he/she is facilitating
a fraud against an insurer, submits an application or files a claim containing
a false or deceptive statement is guilty of insurance fraud.
Applicable in Oklahoma
WARNING: Any person who knowingly and with intent to injure, defraud or
deceive any insurer, makes any claim for the proceeds of an insurance poli-
cy containing any false, incomplete or misleading information is guilty of a
felony.
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1029- ParticipantAccidentClaimForm 3-07 1029 K&K_DRAFT

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