Fill - Free fillable How to File a Medical Claim PDF form

How to File a Medical Claim

(For Special Risk, Sports, Campers, Youth Groups, and Tripster Policies)

Attached is a Blanket Lines Notice of Claim (Claim Form) for your accident policy

Please forward claims and questions to the following address:

Hartford Life Claim Office

Blanket Lines Unit

One Hartford Plaza T-14

Hartford, CT 06155

Toll Free Number: (800) 678-6702

Fax Number: (866) 954-3993

Step 1 - Submit a completed Notice of Claim (claim form) to our office either by fax or mail

The Policyholder (not the Parent, Claimant or Agent) should:

• Fully answer/sign each item in the Policyholder Certification section.

• Read and sign the Fraud Warning Certification statement located on the reverse side of the Notice of

Claim.

The Parent/Guardian or Adult Claimant should:

• Fully answer/sign each item in the Claimant Certification section (choose either the Parent/Guardian

column or the Adult Claimant column; which ever is applicable).

• Read and sign the Fraud Warning Certification statement located on the reverse side of the Notice of

Claim.

Step 2 - Submit itemized medical bills for payment consideration to our office. If the policy is

Excess, (please consult with Policyholder or our office if you are unsure of this) also include

any other insurance carrier’s corresponding Explanation of Benefits (EOBs) as outlined in the

helpful information bullet listed below.

Helpful information for submitting claims and expediting payment

• A fully completed Notice of Claim is required for each accident/injury a Claimant incurs. Claims

submitted with incomplete information will be denied pending receipt of the missing dat a.

•

Release of claim forms by an insurance company is not an admission of coverage. In addition,

information on the form is subject to audit by the insurance company.

• Providers may wish to bill us directly for their services. If they do, please ensure a Notice of Claim

has first been submitted to our office.

• Itemized medical bills (including claimant name, date of service, diagnosis, procedure codes, amount

charged, and provider information) should be submitted for processing. “Balance Due” statements

and/or incomplete bills do not provide enough claim detail to process the charges. In order to ensure

we receive complete claim information, we suggest providers submit standardized billing statements

(called “UB-04” for hospital charges and/or a “CMS-1500” for physician charges).

• Unless proof of payment is submitted with the medical bill (a copy of check, a medical bill that

indicates the claimant has made all or partial payment or zero balance information) claim payment is

generally sent directly to the medical providers.

Please detach this page and forward the completed Notice of Claim (and medical bills if you are submitting

expenses for payment) to the address listed above. We recommend you keep copies of the correspondence

you are submitting to use for future reference.

LC-4028-32 Page 1 of 3 04/2017

HARTFORD LIFE INSURANCE COMPANY

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Notice of Claim

( )

FOR SPECIAL RISK, SPORTS, CAMPERS, YOUTH GROUPS & TRIPSTER POLICIES

Hartford Life Claim Office - Blanket Lines Unit, One Hartford Plaza T-14, Hartford, CT 06155

Toll Free (800) 678-6702 Fax (866) 954-3993

POLICYHOLDER CERTIFICATION - To be completed by Policyholder Official

Policyholder Number

Policyholder Name

Policyholder Email Address Policyholder Phone Number

Policyholder Address

(Street, City, State & Zip Code)

Claimant (Injured Party) Name Date of Accident (mm/dd/yyyy) Time of Accident (hh:mm)

Place of Accident

Cause of Accident

Indicate injured body part(s)

Nature of Sickness (if applicable)

Date sickness first commenced

Policyholder Certification Signature Required:

I hereby certify the Claimant is a member of the group insured

under the above Policy and the injury/sickness was

sust

ained under adequate supervision while p

articip

ating in an of

ficial Covered

Activity

. I further certify I have read

and signed the Fraud W

arning st

atement located on the reverse side of this form.

itle of Policyholder Of

ficial Signature of Policyholder Of

ficial Date

CLAIMANT CERTIFICATION - To be completed by Parent/Guardian or Adult Claimant

*Due to Government regulations, Medicare Beneficiary and Social Security Number information is required for all Claimants

(including children & adults). Claims submitted with incomplete information will be returned.

Parent/Guardian completes for dependent child

Claimant (Dependent child) Name Claimant Gender

Male Female

*Is the Claimant a Medicare Beneficiary? Yes No

If yes, please provide Claimant's Social Security Number.

Claimant Date of Birth Phone or Email Address

Claimant Address

(Street, Apartment, City, State, Zip)

Does the Claimant have medical coverage through?

Mother’s employers policy*

Yes

Father’s employers policy*

Yes

Guardian’s employers policy*

Yes

Medicare policy Yes No

Medicaid policy

Yes No

Any other medical policy* Yes No

If yes, and this Policy is Excess, please include the

other insurance carrier’s Explanation of Benefits (EOBs)

for each medical bill submitted.

Adult Claimant completes

Claimant Name Claimant Gender

Male Female

*Is the Claimant a Medicare Beneficiary?

Yes No

If yes, please provide Claimant's Social Security Number.

Claimant Date of Birth

Phone or Email Address

Claimant Address

(Street, Apartment, City, State, Zip)

Do you have medical coverage through?

Spouse’s employer*

Yes No

Your employer*

Yes

Medicare policy

Yes

Medicaid policy

Yes

Any other medical policy*

Yes

If yes, and this Policy is Excess, please include the

other insurance carrier’s Explanation of Benefits (EOBs)

for each medical bill submitted.

Parent/Guardian or Adult Claimant Certification Signature Required

I certify the above information to be true and accurate to the best of my knowledge. I further certify I have read and

signed the Fraud Warning Certification statement located on the reverse side of this form. I also authorize any physician /

hospital that has attended me or my dependent child to disclose information acquired for claim payment purposes.

Printed Name Parent/Guardian or Adult Claimant

Signature of Parent/Guardian or Adult Claimant

Date

LC-4028-32 Page 2 of 3 04/2017

Clear Form

Signature - Please read the statement that applies to your state of residence and sign the bottom of the page.

With the exception of any source(s) of income reported above in this form, I certify by my signature that I have not received and am not

eligible to receive any source of income, except for my disability benefits from this plan. Further, I understand that should I receive

income of any kind or perform work of any kind during any period The Hartford has approved my disability claim, I must report all details

to The Hartford, immediately. If I receive disability income benefits greater than those which should have been paid, I understand that

I will be required to provide a lump sum repayment to the Plan. The Hartford has the option to reduce or eliminate future disability

payments in order to recover any overpayment balance that is not reimbursed.

For residents of all states EXCEPT Arizona, California, Colorado, Florida, Kentucky, Maine, Maryland, New Jersey, New

York, Oregon, Pennsylvania, Puerto Rico, Tennessee, Virginia and Washington: 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.

For Residents of 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.

For Residents of 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 fines and confinement

in state prison.

For residents of 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 award payable from insurance proceeds shall be reported to the Colorado Division of

Insurance within the Department of Regulatory Agencies.

For residents of 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 t

hird degree.

For residents of Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a

statement of claim or an application for insurance 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.

For residents of Maine, Tennessee, 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

and denial of insurance benefits.

For Residents of Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or

benefit and 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.

For residents of New Jersey: Any person who knowingly files a statement of claim containing any false or misleading

information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an

application for insurance policy is subject to criminal and civil penalties.

For residents of 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.

For residents of Oregon: 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 that the insurer relied upon is subject to a denial and/or reduction in insurance benefits

and may be subject to any civil penalties available.

For residents of 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 hereto commits a fraudulent insurance act, which is a crime and subjects

such person to criminal and civil penalties.

For residents of 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

benefit, 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 by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars

($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present,

the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may

be reduced to a minimum of two (2) years.

For residents of Virginia: Any person who, with the 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 may have violated the state law.

The statements contained in this form are true and complete to the best of my knowledge and belief.

Signature

Date

LC-4028-32 Page 3 of 3 04/2017

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