Fill - Free fillable Medical Claim Form (to expedite your claim, please (University of Texas System) PDF form

Medical Claim Form

IMPORTANT NOTICE: Written notice of claim must be provided within 90 days of the loss. Written

proof of loss must be provided within 90 days after the date of loss. If it cannot be provided within that

time period, it should be sent as soon as reasonably possible. In no event, except in the absence of legal

capacity, will proof of loss be accepted more than one year from the date it was otherwise required.

Please mail your completed Claim Form with itemized bills and receipts to:

(to expedite your claim, please fax it with readable receipts)

Chubb USA (800) 336 0627 Inside USA

PO Box 5124 (302) 476 6194 Outside USA

Scranton, PA 18505-0556 (302) 476 7857 Fax

ACEAandHClaims@chubb.com

Please complete Sections A, B, C, & E. Complete Section D if the claim is for a dependent, other

coverage is in effect, or if the claim is accident related. Complete a separate Claim Form for each

individual.

Section A. Policyholder/Patient Information

Policyholder: Policy Number:

Insured’s Name: Date of Birth:

Patient’s Name: Date of Birth:

Home Address:

Please provide telephone and facsimile numbers, with country and city codes.

Home #: Work #: Fax #:

E-mail:

Manager: E-mail:

Work #: Fax #:

Section B. Travel Information

My trip location is in (country of trip):

I/We left the above country on (DD/MM/YY):

I/We visited the following countries:

I/We are expected to return home on (DD/MM/YY):

The purpose of my/our trip was:

Section C. Payment Information

Please complete either Option 1, Option 2 or Option 3

Option 1 - Payment to Insured

Your home address as listed above Direct deposit to your bank account

Name on account: Account #:

Bank Name: Swift Code:

Bank Address: Currency:

IBAN:

Option 2 - Payment to Provider, e.g. hospital, physician

Please complete Provider’s name and address in Section E of this Claim Form

Option 3 - Payment to Policyholder

Policyholder listed below

Policyholder’s Name:

Policyholder’s Address:

Payment Authorization: I authorize payment directly to me or to the healthcare provider in

Section E of this Claim Form.

Insured’s Signature: Date:

Patient’s Signature and Release (Parent or Guardian, if claim is for a minor): I certify, to the

best of my knowledge, that this Claim Form does not contain any false, misleading, or

incomplete information. I authorize the release of all records or other information which may

be necessary to determine claim payment.

Patient’s Signature: Date:

Section D. Other Coverage Information

Complete only if the claim is for a dependent and/or other coverage is in effect or if the claim is

accident or work related.

Do you have any other insurance? Yes No

If yes, please provide source of insurance:

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Is this claim accident related? Yes No Is this claim work related? Yes No

If yes, please provide documents relating to accident or work injury.

If claim is due to accident, are you seeking reimbursement from another source? Yes No

If yes, please provide source:

Spouse’s Name: Spouse’s insurance company:

Dependent’s date of birth: Is your dependent a full-time student? Yes No

If yes, please provide documentation of current academic registration

Section E. Physician or Provider

Name of physician or provider: Phone #:

Address:

Diagnosis or nature of illness or injury:

Date of illness (first symptom) or injury:

Date first consulted for this condition:

Hospital confinement dates: From To Date able to return to work:

Total disability dates: From To Partial disability dates: From To

Patient’s account #: Amount paid: Balance due:

Place of service:

Diagnosis code and description:

Authorization and Assignment of Benefits

I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional,

pharmacy, Insurance support organization, governmental agency, group policyholder, Insurance company,

association, employer or benefit plan administrator to furnish to the Insurance Company named above or its

representatives, any and all information with respect to any injury or sickness suffered by, the medical history of, or

any consultation, prescription or treatment provided to, the person whose death, injury, sickness or loss is the basis

of claim and copies of all of that person’s hospital or medical records, including information relating to mental

illness and use of drugs and alcohol, to determine eligibility for benefit payments unde

r the Policy Number

identified above. I authorize the policyholder, employer or benefit plan administrator to provide the Insurance

Company named above with financial and employment-related information. I understand that this authorization is

valid for the term of coverage of the Policy identified above and that a copy of this authorization shall be considered

as valid as the original.

I agree that a photographic copy of this Authorization shall be as valid as the original.

I understand that I or my authorized representative may request a copy of this authorization.

I understand that I or my authorized representative may revoke this authorization at any time by

providing the insurance company with written notification as to my intent to revoke.

Signature of Insured or Authorized Representative:

Relationship (if other than Insured): Dated:

Address:

Fraud Warning: Certain states require specific state mandated fraud language to be included on all claims forms while other

states use a generalized fraud stated. We have adopted the fraud warning language prescribed by the District of Columbia as its

standard fraud statement. Unless otherwise noted below this statement shall be included on all claims forms, applications and

enrollment forms.

District of Columbia Generic 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.

The following states have required us to use state specific language as follows:

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.

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.

Florida

Any person who knowingly and with intent in injure, defraud, or de

ceive 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.

New York

Any person who knowingly and with to defraud any insurance company or other perso

n 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 thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed

$5,000 and the stated value of the claim for each such violation.

Oklahoma

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes ant claim for the process

of an insurance policy containing any 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 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 subjects such person to criminal and civil penalties.

Maryland/Oregon

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 may be guilty of insurance fraud.

Virginia

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 may have violated state law.

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