Fillable Boston Mutual - Accident Claim Form 916-701

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Boston Mutual - Accident Claim Form 916-701

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BOSTON MUTUAL LIFE INSURANCE COMPANY
HOME OFFICE: 120 Royall Street
•
Canton, MA 02021
ADMINISTERED BY: PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY
PO Box 34952
•
Omaha, NE 68134-9832 – TEL 1-888-453-5120
•
FAX 1-888-453-5127
ACCIDENT CLAIM FORM
INSTRUCTIONS:
1. Please make sure all questions on this form are completed.
2. If we request an authorization form from you, please complete, sign and date the authorization form we’ve included.
3. For Accident claims, please attach itemized hospital bills, physician bills or medical records documenting the injuries and
treatment received.
4. For Sickness - Hospital Connement claims, please attach the itemized hospital bill and medical records documenting the
reasonfortheconnement.
5. For Wellness Benet claims, please check this box q and attach the itemized bill or medical documentation showing
you received a covered health screening test.
6. Please read the Fraud Notices.
7. Please mail all correspondence and completed claim form to PO Box 34952, Omaha NE 68134-9632 or fax to
1-888-453-5127.
Policyowner’s full name Policy number
Address Daytime telephone No.
STREET CITY STATE ZIP CODE
q Check if this is a new address Policyowner’s Social Security No.
Mailing address (if dierent)
Name and telephone number of employer
Patient’s full name Date of birth Relationship to policyowner
PLEASE PROVIDE ALL INFORMATION REQUESTED ON THIS FORM TO AVOID ANY DELAYS IN THE PROCESSING OF
YOUR CLAIM.
1. COMPLETE THIS SECTION IF CLAIM IS FOR ACCIDENT:
Give the date of the accident / / Location of accident
Explain how the accident happened (if due to a motor vehicle accident, attach a copy of the accident report)
List all injuries received
Didtheaccidentoccurwhileworkingforpayorprot?q Yes q No
Ifyes,wastheaccidentcoveredbyanystateorfederalworker’scompensation,employer’sliabilityoroccupationaldiseaselaw?
q Yes q No
Name and address of treating physician
2. COMPLETE THIS SECTION IF FILING A CLAIM UNDER THE OPTIONAL SICKNESS-HOSPITAL CONFINEMENT
BENEFIT RIDER:
Conditionclaimisbeingledfor
Datesymptomsrstnoticed//
Names and addresses of doctors seen
List the name and address of your regular or family physician
For claim questions call toll free 1-888-453-5120
916-701 3/15
FAMILY MATTERS. NO MATTER WHAT.
3. Haspatienthadthesameorsimilarconditionbefore?q Yes q No If yes, give details
4. Haspatienthadothermedicaltreatmentduringthepastveyears?q Yes q No
If yes, describe conditions and list names and addresses of doctors consulted and dates seen
5. Waspatienthospitalizedasaresultofthisclaim?q Yes q No
If yes, provide name and address of hospital
Admission Date / / Discharge Date / /
6. IfyourpolicywasissuedwithaWaiverofPremiumBenetRider,pleaseanswerthefollowing:
 IsthePayorofthispolicytotallyorpermanentlydisabled?q Yes q No
WARNING: Any person who knowingly and with intent to defraud any insurance company or other person les 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. By signing below, you agree under penalties of perjury that the information in this
statement is complete and true to the best of your knowledge. Please refer to “Fraud Warning Notices” insert for your
state.
I certify that the above statements are true and correct.
Date / / Policyowner’s signature
For claim questions call toll free 1-888-453-5120
916-701 3/15
PROTECTING YOUR INFORMATION
To protect your nonpublic personal information, we maintain: physical, electronic and procedural safeguards.
COLLECTING INFORMATION
We collect information about you in order to conduct business. Such uses are: to process requests for insurance products, to
provide customer service, to process claims, to fulfill legal and regulatory requirements and for other lawful purposes. We
collect this information from you, as well as from other sources. We restrict access to your information to those working on
our behalf who have a need to know it in order for us to provide products and services to you. We require them to secure the
information and keep it confidential.
4 Information we collect may include all the information you share with us including, for example, your:
• name • employer name and income
• address • beneficiary data
• telephone number • financial account numbers
• date of birth • medical information
• social security or tax identification number • and other information you share with us
4 We may also collect data we receive from other sources, as allowed by law, which may include:
• medical information
• consumer report information in accordance with
the Fair Credit Reporting Act
SHARING INFORMATION
We do not share information about our customers or former customers with anyone, except as permitted or required by law.
4 We may share your information with third parties without your authorization as permitted by law. Such information is
used on our behalf by these third parties to:
• process or service your insurance transactions
with us
• perform underwriting, administrative, account
maintenance and claims functions
4 We may also share your information with:
• a consumer reporting agency in accordance with the Fair Credit Reporting Act
• a third party to comply with federal, state or local laws, subpoenas, or summonses
• regulators
• or as otherwise permitted or required by law.
Third parties receiving information from us are required to: keep it confidential and to comply with all applicable federal and
state privacy laws.
ACCESS TO YOUR INFORMATION WE HAVE IN OUR RECORDS
You have the right to request access to all the information we have on you. You must make your request in writing at the
address below.
AMENDMENTS TO YOUR INFORMATION
You have the right to request an amendment, correction or deletion of information which we hold about you which you believe
may be inaccurate. We are not obligated to make updates to your data based on your request. You must make the request in
writing and state the reasons you are requesting the change. Write us at the address below.
If you have questions about this notice or would like more information about our privacy policies, please write us at:
Boston Mutual Life Insurance Company
Attention: Privacy Office
120 Royall Street • Canton, MA 02021
420-012 3/15
• participant information from organizations that purchase
products or services from us for the benefit of their members
or employees, such as group insurance
• information to assist us in complying with state and federal
laws
• provide customer service or reinsurance coverage
• prevent fraud
• perform other business functions on our behalf
NOTICE OF INFORMATION PRIVACY PRACTICES
Boston Mutual Life Insurance Company
(Herein referred to as “we”, “us”, “our”)
FAMILY MATTERS. NO MATTER WHAT.
FRAUD WARNING NOTICES
For Use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
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
insurance 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 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 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.
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.
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 infor-
mation 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 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: Any person who knowingly and with intent
toinjure,defraud,ordeceiveanyinsurer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.
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
insurance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 payment 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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 NH ev. Stat.
Ann.§638:20.
see other side
916-707 7/15
Page 1 of 2
NEW JERSEY: Anypersonwhoknowinglylesastatement
of claim containing any false or misleading 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: Any person who knowingly and with intent to
defraudanyinsurancecompany or otherpersonlesan
application for insurance of 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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 deceptive
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, 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 may be guilty of insurance fraud.
PENNSYLVANIA: Any person who knowingly and with
intenttodefraudanyinsurancecompanyorotherpersonles
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.
ALL OTHER STATES: Any person who knowingly and with
intent to defraud any insurance company or other person
les 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.
PUERTO RICO: Any person who knowingly 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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 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.
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
insurance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, incom-
plete 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.
VIRGINIA: It is a crime to knowingly provide false, incom-
plete 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
insuranceisguiltyofacrimeandmaybesubjecttonesand
connementinprison.
916-707 7/15
Page 2 of 2
FRAUD WARNING NOTICES (cont.)
For Use with Claim Forms
PLEASE READ THE FRAUD WARNING NOTICE FOR YOUR STATE
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Boston Mutual - Accident Claim Form 916-701

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Completed 26 May 2020

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