QBE K12 Claim Form 2015-05-13
PART I – POLICYHOLDER’S REPORT
1. Claimant’s Name (injured/ill person) 2. Social Security Number 3. Gender
M F
4. Date of Birth 5. E-Mail
6. Address of Injured Person 7. Phone Number (include area code)
8. Parent/Legal Guardian Name, Address, City, State & Zip 9. Phone Number (include area code)
10. Date of Accident/Illness 11. Time of Accident
a.m. p.m.
12. Place where Accident Occurred 13. Date of First Treatment
Dental
Claims
14. Indicate which Teeth were Involved in the Accident 15. Describe Condition of Injured Teeth Prior to Accident:
Whole, Sound, and Natural Filled Capped Artificial
16. Type of Injury (Indicate Part of Body Injured – e.g. broken arm, sprained ankle, etc.) Did Injury Result in Death? Yes No
17. Describe How Accident Occurred or the Nature of the Illness – Give all possible details
18. Which Best Describes the Activity:
Play or practice of interscholastic sports
Not school related
Off campus lunch hour
On campus lunch hour
In school bus
School sponsored field trip
Traveling to/from school
On school property during school hours
School sponsored activity during school hours
Other ________________________________
19. Name of Person Supervising the Activity Witness to Accident?
Yes No
20. Type of Activity or Sport
Signature of Parent/Legal Guardian:
X Date:
Signature of School Official:
X Date:
PART II – OTHER INSURANCE STATEMENT
Do you/spouse/parent have medical/health care or is the Claimant enrolled as an individual, employee or dependent member of a Health Maintenance Organization (HMO) or
similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through your employer or other source on you or, if applicable, does your
son/daughter have health care coverage as a dependent from your previous marriage as mandated in a divorce decree?
Yes No
If Yes, name of insurance company Policy #
Name of insurance company Policy #
If applicable, claimant’s primary employer name, address, and phone number
If applicable, mother’s primary employer name, address, and phone number
If applicable, father’s primary employer name, address, and phone number
IF OTHER INSURANCE OR HEALTH CARE PLANS EXIST, PLEASE SUBMIT COPIES of their EXPLANATION OF BENEFITS along with your claim.
IF NO OTHER INSURANCE or HEALTH PLAN EXISTS, PLEASE READ & SIGN BELOW.
I agree that should it be determined at a later date there is insurance (or similar), to reimburse HEALTH SPECIAL RISK, INC., or the insurance company to the extent
of any amount collectible.
Signature of Parent/Legal Guardian:
X Date:
Signature of Witness:
X Date:
PART III – AUTHORIZATION TO PAY BENEFITS TO PROVIDER
I hereby authorize medical payments to be made directly to doctor(s), hospital(s), or indicated provider(s) of service(s) in connection with this claim.
(If not signed submit proof of payment)
SIGNATURE ___________________________________________________________________________________________________________ DATE ______________________
I hereby authorize any insurance company, hospital, physician or other person who has attended or examined the claimant to disclose when requested to do so, all information
with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A photo static copy of this
authorization shall be considered as effective and valid as the original.
SIGNATURE DATE
P.O. Box 117558
Carrollton, Texas 75011-7558
Phone: (972) 512-5600 Fax: (972) 512-5818
Toll Free (866) 409-5734
E-mail : K12claims@hsri.com
1. Please fully complete this form
2. Attach itemized bills
3. Mail, E-mail or Fax to HSR
STUDENT CLAIM FORM
School District:
School Name:
Policy Number:
District Paid ____Voluntary____
Martin Community College
SHH010042
click to sign
signature
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signature
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QBE K12 Claim Form 2015-05-13
FRAUD STATEMENTS
FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW:
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.
Alaska
and Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any
materially false, incomplete or misleading information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime and 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, Louisiana, Maryland, West Virginia &Rhode Island
: Warning: 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 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.
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.
Connecticut
: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a
claimed injury may be guilty of a felony.
Delaware, Idaho, Indiana
: 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.
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
: WARNING :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 to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines
or imprisonment, or both.
Georgia:
Any natural person who knowingly or willfully
1) Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing:
a) In any written statement;
b) In the filing of a claim; or
c) In the receiving of money for an application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false or
fraudulent claim or other benefit by an insurer;
2) Receives money for the purpose of purchasing insurance and converts such money to such persons own benefit;
3) Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or
4) Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement for the purpose of fraudulently
obtaining money or benefit from an insurer commits the crime of insurance fraud.
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 a denial of insurance benefits.
Michigan, North Dakota, South Dakota
: Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties.
Minnesota
; A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
Nevada:
Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a
criminal act punishable under state or federal law, or both, and may be subject to civil penalties.
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.
New Mexico and 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.
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.
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.
Oregon
: Warning: Any person who knowingly, and with intent to defraud any insurance company or other persons 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, may be subject to
prosecution for insurance fraud.
Tennessee, Virginia, Washington
: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
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.
QBE K12 Claim Form 2015-05-13
Listed below are important instructions and comments about filing a claim.
YOUR CLAIM FORM
1. This claim form should be fully completed and submitted within 90 days from the date of
injury. Be sure to answer and complete the section regarding “OTHER INSURANCE
STATEMENT”, marking either yes or no, and signing the line for authorization, so that
HSR and the doctors/hospital may communicate concerning your claim.
Incomplete claim forms are one of the most frequent reasons why claim payments are
delayed.
2. Only one claim form for each accident needs to be submitted.
3. Once completed, make a photocopy for your records, and mail to the address shown below.
4. DO NOT assume that anyone else will mail this claim form to HSR for you.
YOUR BILLS
1. Please advise all doctors/hospitals regarding this coverage so they may forward us their
itemized bills.
2. If you have already been to the doctor/hospital and did not know about this coverage, then
please send all of the itemized bills to HSR at the address shown below.
3. The bills should include the name of the doctor/hospital, their complete mailing address,
telephone number, the date you were seen by the doctor/hospital, what the doctor saw you for
(diagnosis) and the specific itemized charges (description of treatment and amount) incurred
(including the CPT/procedure code).
4. If this information is not on the bill when you send this in we will have to contact the
doctor/hospital which will delay the review of your claim. “Balance Due” or “Balance
Forward” statements do not contain sufficient information to complete your claim.
EXCESS INSURANCE
1. This policy provides coverage on a secondary/excess basis. If you have any other primary
insurance coverage you need to send the bills to your primary insurance first.
2. HSR will consider benefits after your other, primary insurance has processed the claim.
3. We will require a copy of your primary insurance Explanation of Benefits (EOB) which you
should receive from your primary insurance letting you know what was paid or denied, and
the reason(s) why.
4. HSR will not be able to consider your claim without this information.
If you have any questions, please contact Customer Service at (866) 409-5734. They are
available from 8:00 a.m. thru 6:00 p.m. central time, Monday – Friday. You may also
forward any documents by fax to (972) 512-5818.
Health Special Risk, Inc.
P.O. Box 117558
Carrollton, TX 75011-7558
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