Fillable Attending Physicians Statement Section 1: To be completed

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Attending Physicians Statement Section 1: To be completed

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RS-19-03-TRV02
Section 1: To be completed by claimant/insured
Name of Claimant/Insured
Policy Number
Address (street, city, state, zip)
Date of Birth Policy Purchase DateTrip Departure Date
Gender
Male Female
About the Claimant
About the Patient - Complete only if different from Insured
Name of Patient
Relationship of Patient to Insured
Was patient traveling with insured?
Yes No
Section 2: To be completed by physician
Diagnosis / ICD-9 Code (primary diagnosis)
Diagnosis / ICD-9 Code (secondary diagnosis)
Date patient rst consulted you for this condition
Date symptoms rst appeared
Has the patient ever had this condition before?
Yes No
If yes, when?
Is this condition an exacerbation or a
complication of an existing condition?
Yes No
If yes, what was that condition?
If the patient was referred from another physician,
name and phone number of that physician
If the patient was referred to another physician,
name and phone number of that physician
Dates of medical visits as they relate to the condition causing the trip cancellation/interruption.
Date of consultation
Describe Condition/Treatment
Has the patient been hospitalized for this condition
or related conditions in the past 12 months?
Yes No
If yes, date of admittance and date of discharge?
About the Diagnosis and Treatment
About the Medical Condition as it relates to Travel
Was the Insured/Traveler unable to travel on the policy purchase date listed in Section 1 above?
Yes No
If the patient was Traveler, did you advise patient to cancel or interrupt the trip due to the medical condition?
Yes No
If yes, please explain:
Date you advised patient to cancel trip:
If no, on what date was it reasonable for the
patient/insured to cancel/interrupt their trip?
Claims Department: Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Phone No: 1-866-889-7409 | Fax: 443-279-2901 | Email: redsky@archinsurance.com
Attending Physician’s Statement
RS-19-03-TRV02
Section 2, continued: To be completed by physician
About the Medical Condition as it relates to Travel, continued
If the patient was non-traveler, did you advise the Traveler to cancel or interrupt the trip due to the non-traveler’s medical
condition?
Yes No
If yes, please explain:
Date you advised Traveler to cancel trip:
If no, on what date was it reasonable for the
patient/insured to cancel/interrupt their trip?
If related to pregnancy, expected delivery date
If the condition was related to pregnancy, when was
the pregnancy rst diagnosed?
Was the patient hospitalized while traveling?
Yes No
Was this an emergency room admission?
Yes No
Name & Location of Hospital
Date Discharged
Date Admitted
Physician Information and Signature
Specialty
License Number
Physician’s Name
Fax NumberPhone Number
Physician’s Signature
Please note: All of the above requested information is necessary for the processing of the Claimant/
Insured’s claim. Any omitted items will delay processing.
Please attach copies of the patient’s ofce records for the 6 months prior to the trip departure 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.
Date
Claims Department: Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031
Phone No: 1-866-889-7409 | Fax: 443-279-2901 | Email: redsky@archinsurance.com
Attending Physician’s Statement
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signature
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Alabama Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or who knowingly presents false information in an application for in-
surance is guilty of a crime and may be subject to restitution, nes, or connement
in prison, or any combination thereof.
Alaska A person who knowingly 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 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 Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance 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 the payment of a loss is
guilty of a crime and may be subject to nes and connement in state prison.
Colorado It is unlawful to knowingly provide false, incomplete, or misleading facts or informa-
tion 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 policy-
holder or claimant for the purpose of defrauding or attempting to defraud the poli-
cyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Depart-
ment of Regulatory Agencies.
Delaware Any person who knowingly, and with intent to injure, defraud or deceive any insurer,
les 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 insurer or any other person. Penalties include impris-
onment 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 Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er les a statement of claim or an application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Idaho Any person who knowingly, and with intent to defraud or deceive any insurance
company, les a statement of claim containing any false, incomplete, or misleading
information is guilty of a felony.
State Notices
The laws of some states require us to furnish you with the following notices:
Indiana A person who knowingly and with intent to defraud an insurer les a statement of
claim containing any false, incomplete, or misleading information commits a felony.
Kentucky Any person who knowingly and with intent to defraud any insurance company or
other person les 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.
Louisiana Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement in prison.
Maine 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.
Maryland Any person who knowingly or willfully presents a false or fraudulent claim for pay-
ment of a loss or benet or who knowingly or 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.
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 com-
pany, les a statement of claim containing any false, incomplete, or misleading in-
formation is subject to prosecution and punishment for insurance fraud, as provided
in RSA 638:20.
New Jersey Any person who knowingly les a statement of claim containing any false or mis-
leading information is subject to criminal and civil penalties.
New Mexico 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 CIVIL FINES AND CRIMINAL PENALTIES.
New York Auto claims: Any person who knowingly makes or knowingly assists, abets, solicits
or conspires with another to make a false report of the theft, destruction, damage
or conversion of any motor vehicle to a law enforcement agency, the department of
motor vehicles or an insurance company, commits a fraudulent insurance act, which
is a crime, and shall also be subject to a civil penalty not to exceed ve thousand
dollars and the value of the subject motor vehicle or stated claim for each violation.
All others: Any person who knowingly and with intent to defraud any insurance com-
pany or other person les an application for insurance or statement of claim con-
taining 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 ve
thousand dollars and the stated value of the claim for each such violation.
Ohio Any person who, 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 de-
ceptive statement is guilty of insurance fraud.
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 policy containing any
false, incomplete or misleading information is guilty of a felony.
Oregon Any person who knowingly and with intent to defraud or solicit another to defraud
an insurer: (1) by submitting an application, or (2) by ling a claim containing a false
statement as to any material fact thereto, may be committing a fraudulent insurance
act, which may be a crime and may subject the person to criminal and civil penal-
ties.
Pennsylvania Motor vehicles: Any person who knowingly and with intent to injure or defraud any
insurer les an application or claim containing any false, incomplete or misleading
information shall, upon conviction, be subject to imprisonment for up to seven years
and payment of a ne of up to $15,000.
All others: Any person who knowingly and with intent to defraud any insurance com-
pany or other person les an application for insurance or statement of claim con-
taining 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.
Rhode Island Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement in prison.
Tennessee It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
Texas 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 nes and connement in state prison.
Utah Workers’ Compensation Claims Only: Any person who knowingly presents false or
fraudulent underwriting information, les or causes to be led a false or fraudulent
claim for disability compensation or medical benets, or submits a false or fraudu-
lent report or billing for health care fees or other professional services is guilty of a
crime and may be subject to nes and connement in state prison.
Virginia It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purpose of defrauding the company. Penalties include
imprisonment, nes and denial of insurance benets.
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 include
imprisonment, nes, and denial of insurance benets.
West Virginia Any person who knowingly presents a false or fraudulent claim for payment of a
loss or benet or knowingly presents false information in an application for insur-
ance is guilty of a crime and may be subject to nes and connement in prison.
Puerto Rico Any person who knowingly and with the intention of defrauding presents false infor-
mation 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 convic-
tion, shall be sanctioned for each violation by a ne of not less than ve thousand
dollars ($5,000) and not more than ten thousand dollars ($10,000), or a xed term
of imprisonment for three (3) years, or both penalties. Should aggravating circum-
stances be 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.
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Completed 10 September 2021

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