Fillable Accidental Death Claim Form Accidental Death Claim Instructions (Trip Preserver online claims)

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Accidental Death Claim Form Accidental Death Claim Instructions (Trip Preserver online claims)

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Accidental Death
Claim Form
Claims Department:
Red Sky Claims, C/O Arch Insurance Company | Executive Plaza IV | 11350 McCormick Road, Suite 102 | Hunt Valley, MD 21031
Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
Accidental Death Claim Instructions
The Claimant/ Insured should complete and sign the Accidental Death Insurance claim form in full and return it with the
documentation noted below.
For all claims, submit:
•Copiesoftheinsured’straveldocumentsconrmingthetraveldatesanditinerary;
•Acopyoftheaccidentreport;
•Acopyofthepolicereportoftheaccident;
•Anal,certiedcopyoftheinsured’sdeathcerticate;
•Acopyoftheautopsyreport,ifperformed;
•Acopyoftheinquestreport,ifheld;
•Medicalrecordsoftheinjuryandtreatment;
•Newspaperorotherarticlescontainingdetailsoftheaccident;
•Anyotherinformationordocumentationthatwouldhelptoexplainthecircumstancesoftheinsured’saccident
and death.
Your claim should be submitted to the address at the top of these instructions.
Accidental Death
Claim Form
Name of Claimant / Insured
NameofBeneciary
RelationshipofBeneciarytoInsured
Name of person driving the vehicle at the time of the accident:
Date and time of accident
Did death occur as the result of a motor vehicle accident?
Facilitywheretheinsuredwastreatedaftertheaccident:
Email Address
PolicyNo.
Phone No.
To be Completed by Beneciary Claiming Benets
SocialSecurityNumber
SocialSecurityNumber
Address
AddressofBeneciary
Describe how accident occurred:
Location of Accident
Witness/Passenger Information
Witness/Passenger Information
Street
Name
Name
City
Address
Address
State
Phone No.
Phone No.
Country
Traveling Companion(s
) Relationship
Male
Female
Male
Female
AM
PM
Yes No
Date of Birth
Date of Birth
Trip Departure Date
Initial Trip Deposit Date
Date of Death
Trip Return Date
( )
( )
( )
Claims Department:
Red Sky Claims, C/O Arch Insurance Company | Executive Plaza IV | 11350 McCormick Road, Suite 102 | Hunt Valley, MD 21031
Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
Accidental Death
Claim Form
Other Drivers Involved
Other Drivers Involved
Name
Name
Address
Address
Phone No.
Phone No.
( )
( )
( )
Nameoflawenforcementagencyinvestigatingtheaccident Phone No.
Wasanyonecitedbythepolice?
Wasaninquestheld?
Wasanautopsyperformed?
Name of court holding hearing:
Pleaseexplain:
Ifyes,pleasesubmitacopyofthereport.
Yes No
Yes No
Yes No
Signature of Beneciary/Claimant Date
Anypersonwhoknowinglyandwithintenttoinjure,defraudordeceiveanyinsurancecompany,lesastatementofclaim
containinganyfalse,incomplete,ormisleadinginformationmaybeguiltyofacriminalactpunishablebylaw.
Ihavereadtheforegoing,andtheaboveanswersaretrueandcompleteaccordingtothebestofmyknowledgeandbelief.
Claims Department:
Red Sky Claims, C/O Arch Insurance Company | Executive Plaza IV | 11350 McCormick Road, Suite 102 | Hunt Valley, MD 21031
Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
The laws of some states require us to furnish you with the following notices:
WARNING. Any person who knowingly:
Alaska: and with intent to injure, defraud, or deceive an insurance company les a claim containing false, incomplete, or misleading information may be
prosecuted under state law.
Arizona, Arkansas and Rhode Island: presents a false or fraudulent claim for payment of a loss or benet is subject to criminal and civil penalties, or specic to
AR and RI: presents false information in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.
California: For your protection 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 nes and connement in state prison.
Delaware: and with intent to injure, defraud or deceive an insurer, les a statement of claim containing any false, incomplete or misleading information is guilty of
a felony.
District of Columbia: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person.
Penalties include imprisonment and/or nes. In addition, an insurer may deny insurance benets if false information materially related to a claim was provided by
the applicant.
Florida: and with intent to injure, defraud, or deceive any insurer, les a statement of claim or application containing any false, incomplete, or misleading
information is guilty of a felony of the third degree.
Idaho and Indiana: and with intent to defraud or deceive any insurance company, les a statement of claim containing any false, incomplete, or misleading
information (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 les an application for insurance, or les a statement
of claim, containing any materially false information or conceals, for the purpose of misleading, information concerning any material fact thereto commits a
fraudulent insurance act, which is a crime, specic to PA: subjects such person to criminal and civil penalties and specic to NY: shall also be subject to a civil
penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.
Louisiana, New Mexico, Texas and West Virginia: presents a false or fraudulent claim for the payment of a loss (or specic to LA, TX and W VA: who knowingly
presents false information on an application for insurance) is guilty of a crime and may be subject to nes and connement in state prison, (or specic to
NM: to civil nes and criminal penalties.)
Maryland: and willfully presents a false or fraudulent claim for payment of loss or benet or who knowingly and willfully presents false information in an application
for insurance is guilty of a crime and may be subject to nes and connement in prison.
New Jersey: les a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
Ohio: with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or les a claim containing a false or deceptive
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 information is guilty of a felony.
Oregon: and with intent to defraud any insurance company or other person les an application for insurance or a statement of claim containing any materially
false information or conceals for the purpose of misleading, information concerning any fact material hereto, may be subject to prosecution for insurance fraud.
Puerto Rico: and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a
fraudulent claim for the payment of a loss or any other benet, or presents more than one claim for the same damage or loss, shall incur a felony and, upon
conviction, shall be sanctioned for each violation with the penalty of a ne of not less than ve thousand (5,000) dollars and not more than ten thousand (10,000)
dollars, or a xed term of imprisonment for three (3) years, or both penalties. If aggravating circumstances are present, the penalty thus established may be
increased to a maximum of ve (5) years; if extenuating 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 information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, nes, 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.
Hawaii: Presenting a fraudulent claim for payment of a loss or benet is a crime punishable by nes or imprisonment, or both.
Maine/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, nes or a denial of insurance benets.
Minnesota: A person who les 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, les 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.
Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurer or insurance company for the purpose of
defrauding the insurer or insurance company. Penalties include imprisonment, nes and denial of insurance benets.
Authorization to Disclose Information
To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of
any medical information about me to Arch insurance Company, or it’s authorized representative. This applies to all information about the
diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past.
To any insurance company, any travel organization or agency, airline carrier, cruise line, tour operator, rental agency, hotel, motel, or
similar entity providing lodging on a rental / lease basis or any other person who may have knowledge regarding this claim: I authorize
the release any information requested regarding this claim and the loss reported.
The company will use this information to determine if any claim is eligible. Any information obtained will not be released by the
Company except to my primary health insurance carrier (if any) or persons or organizations performing investigation or legal services
for the Company in connection with my claim. A copy of this authorization shall be considered as effect and valid as the original and
shall remain in effect for one year from the date of authorization.
I certify that the information given by me in support of my claim is true and correct. I understand that any person who knowingly and
with intent to defraud or deceive any insurance company, les a claim containing any materially false, incomplete or misleading
information may be subject to prosecution or insurance fraud.
Beneciary or Authorized Representative’s Signature
If Authorized Representative, Relationship to Beneciary
or Legal Designation
Date
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Accidental Death Claim Form Accidental Death Claim Instructions (Trip Preserver online claims)

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Completed 12 September 2021

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