Fillable Accidental Death Claim Instructions (Trip Preserver online claims)

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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 USA
Toll Free Phone: (844) 800-2486 | 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 USA
Toll Free Phone: (844) 800-2486 | 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 USA
Toll Free Phone: (844) 800-2486 | 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.
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 Instructions (Trip Preserver online claims)

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Completed 12 September 2021

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