Fill - Free fillable Accident Claim Form36-10347 PDF form

ACCIDENT CLAIM FORM

MAIL TO:

NAHGA

Claim Services

P.O. Box 189

Bridgton, ME 04009

Email: claims@nahga.com

File claims electronically: Payer ID 67788 Questions: Contact 800-952-4320 Fax: 207-647-4569

INSTRUCTIONS ( SIGNATURE SECTION MUST BE COMPLETED AT THE BOTTOM OF ALL THREE PAGES)

● All fields must be completed

● Part I – Must be completed by Policyholder

● Part II – Must be completed by Claimant or by the Parent or Guardian, if the Claimant is a minor

● Send copies of itemized bills showing provider’s name, address, tax ID number, diagnosis and procedures codes.

● Attach explanation of benefits, additional bills with record of payment or denial from primary insurance carrier.This does not apply if

the accident policy provides primary coverage

● All benefits will be payable to the physicians and providers, unless accompanied by paid receipts

● If employed, but have no other insurance, forward employer(s) letter on employer(s) letterhead to that effect.

● For additional instructions about how to file a claim please visit www.ajfusa.com/claims

Claimants eligible for Medicaid benefits must first file for benefits under this policy before submitting expenses to Medicaid.

PART I – POLICYHOLDER REPORT (Signature is required at the end of this section)

1. Policy Number:

2. Name of Policyholder:

3. Policyholder Address:

4. City: State: Zip:

5. Policyholder Contact: Email:

Phone: Fax:

6. Last name of Claimant: First name of Claimant:

7. Social Security Number: Date of Birth:

8. Sex: 0Dle )emale

9. Grade (if applicable): Check one (if applicable) Day School Boarding

10.

Nature of injury: (Describe, fully indicate what part of the body was injured – e.g. broken arm, sprained ankle)

Must be a bodily injury due to accident.

11. Describe how the accident occurred, provide all details.

Attach a separate sheet, if necessary (include name of sport / activity)

12. Did the accident occur:

a. During a Policyholder supervised / authorized activity? Yes No

b. During a Policyholder sponsored activity? Yes No

c. During scheduled Policyholder hours? Yes No

d. While traveling to or from a Policyholder sponsored and supervised activity? Yes No

e. Off Policyholder premises, at home, during the weekend, holiday or summer vacation? Yes No

13. Date of Accident: Time of Accident: A.M. P.M

Place of Accident:

14. Name and title of person supervising activity:

Was he or she a witness? Yes No

15.

List other Policyholder insurance. Attach a separate sheet, if necessary.

Type of Policy

Policy Number

_____________________________________________

Signature of Authorized Policyholder Representative

Title

Date

Accident Claim Form

Page 1 of 3

03/2016

Print Application

Clear Application

PART II

(To Be Completed by Claimant or Parent / Guardian, if Claimant is a Minor)

Name of Claimant or Father / Guardian:

Social Security Number:

Email Address:

Name of Mother or Guardian:

Social Security Number:

Email Address:

Street address of Parents or Claimant Guardian:

City:

State:

Zip:

Telephone Number:

Father or Guardian’s Insurance Company:

Mother or Guardian’s Insurance Company:

Name and address of Claimant or Father / Guardian’s employer, if a minor:

Employer’s Name:

Employer’s Mailing Address:

City:

State:

Zip:

Name and address of Claimant or Mother / Guardian’s employer, if a minor:

Employer’s Name:

Employer’s Mailing Address:

City:

State:

Zip:

List all other insurance policies under which Claimant is insured:

Type of Policy

Policy Number

The Affordable Care Act requires Philadelphia Indemnity Insurance Company to request verification that no other

coverage is in force from the employer(s) of the claimant or the parent / guardian if under the age of 26.

9. Is the Claimant enrolled in, a member of, or a participant of any of the following as an individual, employee or

dependent? If yes, please provide a copy of the insurance card (front and back).

Preferred Provider Organization (PPO) or similar prepaid health plan?

Yes

If yes, name of PPO Organization:

Health Maintenance Organization (HMO) or similar prepaid health plan?

Yes

If yes, name of HMO or organization:

10.

If Claimant has health care coverage as a dependent from a previous marriage as mandated in a divorce decree,

please provide the following:

Name of Policyholder

Name of Insurance Company

Policy Number

AFFIDAVIT

I verify that the statement on the other insurance is accurate and complete. I understand that the intentional furnishing of incorrect

information via the U.S. Mail may be fraudulent and violate federal laws as well as state laws. I agree that if it is determined at a later

date that there are other insurance benefits collectible on this claim I will reimburse the Company to the extent for which the Company

would not have been liable.

AUTHORIZATION TO RELEASE INFORMATION

I authorize any Health Care Provider, Doctor, Medical Professional, Medical Facility, Insurance Company, person or Organization to

release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including

disability or employment related information

concerning the patient, to Philadelphia Indemnity Insurance Company, its employees and

authorized agents for the purpose of validation and determining benefits payable. I further authorize any Philadelphia Indemnity

Insurance Company to furnish the Policyholder or its agents, any and all information with respect to my insurance claim for the purpose

of assisting with claims adjudication. This data may be extracted for audit or statistical purposes. I understand that I have the right to

revoke this autho

rization in writing at any time and that such a revocation is not effective to the extent that such authorization has

already been relied upon.

PAYMENT AUTHORIZATION (Signature is required at the end of this section)

I authorize all current and future medical benefits, for services rendered and billed as a result of this claim, to be made payable to the

physicians and providers indicated on the invoices, unless paid receipts accompany this form.

_________________________________________________________

Claimant Signature (Parent or guardian, if the claimant is a minor)

Date

Accident Claim Form

Page 2 of 3

03/2016

Clear Application

Print Application

CLAIM FORM FRAUD STATEMENTS (Signature is required at the end of this section)

ALABAMA: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents

false information in an application for insurance is guilty of a crime and may be subject to restitution, fines or confinement in prison or

any combination thereof.

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.

ARKANSAS, RHODE ISLAND AND WEST VIRGINIA: 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.

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.

DELAWARE and IDAHO: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of

claim containing any false, incomplete or misleading information is guilty of a felony.

DISTRICT OF COLUMBIA: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of

defrauding the ins

urer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance

benefits if false information materially related to a claim was provided by the applicant.

FLORIDA: 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.

INDIANA: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or

misleading information commits a felony.

KANSAS: Any person who, knowing and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief

that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support

of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment

or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially

false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact

material thereto commits a fraudulent insurance act.

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 information or conceals, for the purpose of misleading, information concerning any fact material thereto

commits a fraudulent insurance act, which is a crime.

MAINE, TENNESSEE, VIRGINIA, and WASHINGTON: It is a crime to knowingly provide false, incomplete or misleading information to

an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance

benefits.

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.

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, defrauds, 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.

NORTH CAROLINA and OREGON

: 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, commits insurance fraud, which is a crime and

subjects the person to civil and criminal penalties.

OHIO: Any person who, with intent to defraud or knowing that he 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.

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.

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.

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.

NEW YORK: 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.

_______________________________________________

Claimant Signature (Parent or guardian, if the claimant is a minor)

Date

Accident Claim Form

Page 3 of 3

03/2016

Clear Application

Print Application

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

Accident Claim Form36-10347

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank Accident Claim Form36-10347 Form

Related forms

Fillable Accident Claim Form36-10347

Fill Online, Printable, Fillable, Blank Accident Claim Form36-10347 Form

Related forms

First 20 documents completely FREE!