Fillable INSTRUCTIONS Accidental Dismemberment Claim Form Upon a Dismemberment (University of Texas System)

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INSTRUCTIONS Accidental Dismemberment Claim Form Upon a Dismemberment (University of Texas System)

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Return to Blue Cross and Blue Shield of Tex
as at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accidental Dismemberment Claim Form
R040119
| Z6295_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 1 of 7
INSTRUCTIONS
Upon a Dismemberment due to an Accident to an insured employee, plan member or insured dependent, the
employer/administrator must complete the claim form as indicated and send with all necessary attachments.
Please submit the following documentation:
1. Claim Form:
Part 1 – Completed by the Employer/Administrator
Part 2 – Completed by the Insured/Claimant
Part 3 – Completed by the Attending Physician
2. Original, photocopy or screen print of enrollment form, including any beneficiary changes.
3. If the benefits are based on salary, submit payroll records verifying the employee’s annual earnings
at the time of their death.
4. If any portion of coverage is paid for by the employee, submit proof of payroll deduction.
5. For accidental dismemberment benefits, provide the below items, including but not limited to:
a. Official complete police report
b. Newspaper clippings
c. Doctor’s report, including laboratory findings and or/toxicology report.
Return to Blue Cross and Blue S
hield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accidental Dismemberment Claim Form
R040119
| Z6295_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 2 of 7
Part 1 – To be completed by Employer/Administrator
Statement of Employer
Employer/Plan Information
Address
Insured Person Information
Amount of Insurance:
If deceased is a dependent spouse or child, complete the following:
If dependent is a child, is he/she a full-time student
I certify that I have read this document and the information is accurate and complete. I understand that any
person who knowingly files a statement of claim containing any false or misleading information may be subject
to criminal and civil penalties.
Signature of Authorized Employer/Plan Representative __________________________________________________
Group Name
Yes
Subsidiary Name
Group Number GFZ71778
Street City State/Zip
Name and Title of Authorized Representive
Phone Number
Fax Number
E-mail Address
Employee/Claimant Name
If Dependent, Name of Dependent Relation to Employee
Employee Social Security No.
Date of Birth
Address:
Street City
State/Zip
Hire Date Insurance Effective Date Occupation
Date of Last Salary IncreaseAnnual Salary
Basic Life
Supplemental Life
AD&D
Voluntary Life
Dependent Life
Additional Benefits:
Last Day Worked
Reason for cessation of work
If Disabled, Provide date of disability
Dependent's most recent Employer Last Day Worked
No
Name of School
Print Name Date
Return to Blue
Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accidental Dismemberment Claim Form
R040119
| Z6295_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 3 of 7
Part 2 – To be completed by Insured or Claimant
Are you a U.S. Citizen: (If No – IRS Form W-8 required)
(If multiple physicians, please list all. Attach separate sheet if necessary)
Location of Treating Physician
(If multiple hospitals, please list all. Attach separate sheet if necessary)
Location of Hospital
Describe the loss for which benefits are being claimed. (Attach separate sheet if necessary)
Address:
Street City State/Zip
Name
Last First
Middle
Date of Birth
Social Security No.
HT WT
Phone E-mail
Relationship to deceased
Yes No
Date of Accident Date of Loss
Name of Treating Physician
Phone
Street City State/Zip
Street City State/Zip
Name of Hospital where treatment was received
Hospital Phone Number
Admission Date Discharge Date
Return to Blue Cross and Blue Shield of Texas
at: Attention: Claims Department
P.O.
Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accidental Dismemberment Claim Form
R040119
| Z6295_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701
E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of
the Blue Cross and Blue Shield Association. BLUE CROSS®,
BLUE SHIELD® and the Cross and Shield Symbols are registered
service
marks of the Blue Cross and Blue Shield Association, an
association of independent Blue Cross and Blue Shield Plans.
Page 4 of 7
AUTHORIZATION FOR RELEASE OF INFORMATION
I (the undersigned) authorize any physician, medical professional, pharmacist or other provider of health care
services, hospital, clinic, other medical or medically related facility; coroner’s office; insurance or reinsurance
company; government agency; department of labor; law enforcement or public safety department; group policyholder;
employer; or policy or benefit plan administrator to release information from the records of:
Claimant/Insured Information to be released:
• Data or records regarding medical history, treatment, prescriptions, consultations, autopsy (including medical and
psychological reports; records, charts, notes – excluding psychotherapy notes -, x-rays, films or correspondence,
and any medical condition(s));
• Any information regarding insurance coverage; and
• Accident report or any official investigative reports (such as police, fire, FAA, OSHA, or toxicology report).
• Information to be released to:
Blue Cross and Blue Shield of Texas
P.O. Box 7070
Downers Grove, IL 60515
• I understand the information obtained by use of this
Authorization will be used by Blue Cross and Blue Shield of
Texas (BCBSTX) to evaluate my claim for death benefits. The Company will only release such information:
- To its reinsurer, or other persons or organizations performing business or legal services in connection with
my claim(s); or
- As otherwise may be required by law or as I further authorize.
I further understand that refusal to sign this Authorization may result in the denial of benefits.
• I understand the information used or disclosed may be subject to re-disclosure by the recipient and
may no longer be protected by federal law.
• I understand that I may revoke this Authorization in writing at any time, except to the extent;
- The Company has taken action in reliance on this Authorization; or
- The Company is using this Authorization in connection with a contestable claim.
If written revocation is not received, this Authorization will be considered valid for a period of time not
to exceed 24 months from the date of signature below. To initiate revocation of this Authorization, direct all
correspondence to the company at the above address.
• A photocopy of this Authorization is to be considered as valid as the original.
• I understand I am entitled to receive a copy of this Authorization.
Claimant/Legal representative (Nearest relative, legal guardian, or appointed representative to sign only if claimant/
insured is a minor, legally incompetent, or deceased.) Power of attorney or guardianship must be attached.
Claimant/Insured Name
Print Name
Date
SIGNTAURE
Relationship to Claimant/Insured or personal/legal representative signing for Claimant/Insured
Address
Street City State Zip
Phone No.
Last
First Middle
Date of Birth
Re
turn to Blue Cross and Blue Shield of Texas at:
Attention: Claims Department
P.O. Box 7070
Downers Grove, IL 60515
Phone Number: (866) 628-2606
Fax: (312) 540-4706
Accidental Dismemberment Claim Form
R040119
| Z6295_TX_UT
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cross and Blue Shield of Texas is the trade name of Dearborn Life
Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 5 of 7
Part 3 – Attending Physician’s Statement
As a result of this accident, did the patient suffer loss of any of the following? (please check all that apply)
Hand Foot Sight*
*Is loss of sight or hearing complete and irrevocable
Address
Street City State/Zip
Name of Patient
Gender
Date of Birth
Employee Name if other than Patient
Date of Accident Date First Consulted
Was the loss sustained as a result of this accident
Was the loss sustained as a result of this accident
Right Left Right Left Hearing* OS OD Paralysis Other
Yes No
Please describe the loss as indicated above and provide any additional remarks:
Address
Street City State/Zip
Specialist Referral
Date
SIGNTAURE
Physician Name
Speciality
Fax
Telephone
EIN/SSN
Administrative Office: 701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
R040119 I Z6291_LC
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cr
oss and Blue Shield of Texas is the trade name of Dearborn Life
Insurance
Company,
an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 6 of 7
Maryland: Any person who knowingly and willingly presents
a false or fraudulent claim for payment of a loss or benefit or
who knowingly and willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in 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, fines and denial of
insurance benefits.
FOR APPLICATIONS AND CLAIMS:
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 or award
payable from insurance proceeds shall be reported to the
Colorado division of insurance within the department of
regulatory agencies.
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 fines. In addition, an insurer
may deny insurance benefits 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 insurer files a statement of claim or
an application containing any false, incomplete, or
misleading information is guilty of a felony of the third degree.
Hawaii: For your protection, Hawaii law requires you be
informed that presenting a fraudulent claim for payment of a
loss or benefit is a crime punishable by fines or
imprisonment, or both.
Kentucky: Any person who knowingly and with intent to
defraud any insurance company or other person files 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
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 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.
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 include imprisonment, fines and denial of insurance
benefits.
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.
Ohio: Any person who, with intent to defraud or
knowingly that he is facilitating a fraud against an insurer,
submits an application or files a claim containing a false
or deceptive statement is guilty of insurance fraud.
Oklahoma: Any person who knowingly, with intent to
injure, defraud or deceive any insurer, makes a claim for
the proceeds of an insurance policy containing false,
incomplete or misleading information is guilty of a felony.
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 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 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
with the penalty of 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.
Rhode Island: 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.
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, fines and denial of
insurance benefits.
Alabama: Any person who knowingly presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application
for insurance is guilty of a crime and may be subject
to restitution fines or confinement in prison, or any
combination thereof.
Administrative Office:701 E. 22nd Street, Lombard, IL 60148
Fraud Notices
The laws of some states require us to furnish you with the following notice:
R040119 I Z6291_LC
Insurance products issued by Dearborn Life Insurance Company, 701 E. 22nd St. Suite 300, Lombard, IL 60148. Blue Cr
oss and Blue Shield of Texas is the trade name of Dearborn Life
Insurance
Company,
an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service
marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.
Page 7 of 7
FOR CLAIMS ONLY:
Idaho: Any person who knowingly, and with intent
to defraud or deceive any insurance company,
files a statement or claim containing false,
incomplete, or misleading information is guilty of a
felony.
Alaska: A person who knowingly and with intent
to injure, defraud, or deceive an insurance
company files 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
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.
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.
Delaware: Any person who knowingly, and with
intent to injure, defraud or deceive any insurer,
files 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 files a statement of claim
containing any false, incomplete, or misleading
information commits a felony.
Minnesota: A person who files 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, files 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.
New Jersey: Any person who knowingly files a
statement of claim containing any false or
misleading information is subject to criminal
and civil penalties.
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
fines and confinement in state prison.
Massachusetts: 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 APPLICATIONS ONLY:
New Jersey: Any person who includes any
false or misleading information on an
application for an insurance policy is subject to
criminal and civil penalties.
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INSTRUCTIONS Accidental Dismemberment Claim Form Upon a Dismemberment (University of Texas System)

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Completed 13 January 2021

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