Fill - Free fillable Left Body Part Right Body Part (Ranger College) PDF form

PART 1A - POLICYHOLDER

College/University (Policyholder Name)

Policy#

Student’s Name

Date of Birth

Male Female

Date of Injury/Accident

Name of Sport (if applicable)

Body Part Injured

Left Body Part Right Body Part

Type of Sport/Activity: Intercollegiate Sport Club Sport Intramural Sport General Accident

Sport/Activity Situation: Game Practice Conditioning Travel Other: _________________

Was the student involved in an activity sponsored and supervised by the Policyholder? YES NO

How did Injury occur? Please Provide Details of What Happened.

Name of College/University Official:

Title of College/University Official

Signature of College/University Official

Date

NOTE: Part 1A – Policyholder section must be signed by an official of the policyholder or the claim cannot be processed

PART 1B - INJURED PERSON INFORMATION & INSURANCE INFORMATION

Student’s Social Security Number (SSN Must be provided as required by the Center for Medicare Services)

Student’s Home Address (Street, City, State, Zip)

Student’s Phone #

Student’s E-Mail

Is the Student covered by any other insurance policy, either as a dependent, or under a group, individual, automobile,

medical or liability Policy? YES NO If Yes, Name of Ins. Carrier: ___________________________________________

Policy #: ________________ Is the above insurance a Medicaid Plan or a Military Insurance such as Tricare? YES

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name

Phone

E-Mail

Phone

E-Mail

Is the Parent/Guardian Employed?

YES NO

Is the Parent/Guardian Employed?

YES NO

Employer

MEDICAL INFORMATION AUTHORIZATION & ASSIGNMENT OF BENEFITS: I authorize any Health Care Provider, Medical Facility, Doctor, Insurance Company or

Organization to furnish at the request of BMI Benefits, LLC. or the underwriting companies with which it works, information w

hich you may possess including, findings and

reatments rendered and copies of all hospital and medical records for professional services and hospital care rendered on my behalf. The foregoing authorization is granted with

the understanding that any legal rights I may ordinarily have to claims communi

cations between us as privileges are hereby expressly and voluntarily waived. A photostat of this

authorization shall be considered as valid and effective as the original. Payments will be made to the providers of service,

unless a paid receipt/statement is submitted.

Any

person who knowingly and with intent to defraud any insurance company or other person files 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, 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.

Student or Authorized Person’s Signature

Date

P.O. Box 511

Matawan, NJ 07747

Phone: 800.445.3126

Fax: 732.583.9610

www.bobmccloskey.com

Student & Sports Accident Claim Form

Please complete this form in its entirety and submit to BMI Benefits within 90

days from the date of accident. Please retain a copy for your records. Please

contact the medical providers where treatment was received, submit BMI’s

billing information as your secondary insurance, and ask for BMI to be billed

directly. You may also obtain from the medical providers all itemized bills

and primary insurance explanation of benefits (EOBs). Itemized bills are

considered HCFA1500 Forms (physician’s office) or UB-04 Forms

(hospitals), not balance due statements.

CLAIM FORM FRAUD NOTICE

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.

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 pur

pose 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.

Kansas

A "fraudulent insurance act" means an act committed by any person who, knowingly and with intent to

defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to

or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse,

facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an

application for the iss

uance of, or the rating of an insurance policy for personal or commercial insurance, or

a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance

which such person knows to contain materially false informatio

n concerning any fact material thereto; or

conceals, for the purpose of misleading, information concerning any fact material thereto.

Kentucky

Any person who knowingly and with intent to defraud any insurance company or other person files an

application f

or 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.

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

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, or denial of insurance

benefits.

Maryland

Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or

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.

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.

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

General: All applications for commercial insurance, other than automobile insurance: 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, commi

ts 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.

All applications for automobile insurance and all claim forms: 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

insu

rance company, 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 value of the subject motor vehicle or stated claim for

each violation.

Fire:

Any person who knowingly and with intent to defraud any insurance company or other person files an

application for insurance containing any false information, or conceals for the purpose of misleading,

information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

The proposed insured affirms that the foregoing information is true and agrees that these applications shall

constitute a part of any policy issued whether attached or not and that any willful concealmen

t or

misrepresentation of a material fact or circumstances shall be grounds to rescind the insurance policy.

Ohio

Any person who, with 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 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.

Pennsylvania

All Commercial Insurance, Except As Provided for Automobile Insurance: Any person who

knowingly and with intent to defraud any insurance company or other person file

s 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.

Automobile Insurance:

Any person who knowingly and with intent to injure or defraud any insurer files an

application or claim containing any false, incomplete or misleading information shall, upon conviction, be

subject to imprisonment for up to seven years and the payment of a fine of up to $15,000.

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.

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

All Commercial Insurance, Except As Provided for Workers’ Compensation It is a crime to knowingly provide

false, incomplete o

r misleading information to an insurance company for the purpose of defrauding the

company. Penalties include imprisonment, fines and denial of insurance benefits.

Workers’ Compensation: It is a crime to knowingly provide false, incomplete or misleading information to

any party to a workers’ compensation transaction for the purpose of committing fraud. Penalties include

imprisonment, fines and denial of insurance benefits.

Utah

Workers’ Compensation: Any person who knowingly presents false or fraudulent underwriting information,

files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or

submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a

crime and may be subject to fines and confinement 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 imprisonme

nt, fines and denial of insurance

benefits.

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.

West Virginia

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.

All Other

States

Any person who knowingly and willfully presents false information in an application for insurance may be

guilty of insurance fraud and subject to fines and confinement in prison. (In Oregon, the aforementioned

acti

ons may constitute a fraudulent insurance act which may be a crime and may subject the person to

penalties).

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