Fill - Free fillable Primary Medical Expense Claim Form (Trip Preserver online claims) PDF form

Primary Medical Expense

Claim Form

Claims Department:

Red Sky Claims, C/O Arch Insurance Company

Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031

Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com

Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or

knowingly presents false information in an application for insurance is guilty of a crime and may be

subject to nes and connement in prison.

To be Completed by Insured / Guest

Name of Insured / Guest Reservation #

Address Work Phone # Home Phone #

Date of Birth (mm/dd/yy) E-mail Address

Date of Initial Trip Deposit (mm/dd/yy) Scheduled Departure Date (mm/dd/yy) Scheduled Return Date (mm/dd/yy) Date Incident Occurred (mm/dd/yy)

Name and Address of Property Management Company Phone #

Fax #

Name of leaseholder on the rental property and list all guests occupying the property

Name of Patient Relationship to Insured / Guest

Are you a U.S. Citizen? Date symptoms rst appeared (mm/dd/yy)

Give Nature of Sickness or Injury (Diagnosis) Date of initial treatment for this condition (mm/dd/yy)

Describe fully how, when and where Sickness / Injury Occurred

Was there previous treatment for these conditions prior to purchase of plan?  Yes  No If yes, when?

Name and address of primary care physician where you reside Physician’s Phone # Physician’s Fax #

Name and address of other physician(s) who treated the condition Physician’s Phone # Physician’s Fax #

Name and address of Hospital (if hospitalized) Date Admitted and Discharged Hospital Phone #

Was an accident report led for this incident? If yes, please provide a copy.

Note: Your Travel Insurance Policy is Primary to any other health, medical, and travel insurance you may have.

Do you have any other medical Insurance?

Please list all of your other medical insurance plans (group health, Medicare, supplemental, etc.)

Arch-2014

 Yes  No

( ) ( )

( )

( ) ( )

( )

 Yes  No

Primary Medical Expense

Claim Form

Claims Department:

Red Sky Claims, C/O Arch Insurance Company

Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 21031

Toll Free Phone: (866) 889-7409 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com

Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or

knowingly presents false information in an application for insurance is guilty of a crime and may be

subject to nes and connement in prison.

Please include the following items with your claim forms after completing page 1 of this form. Any

omitted items will delay processing. You may want to send any valuable documents by certied mail.

3 Your cancelled check or credit card statement for the initial trip deposit.

3 Copies of explanation of benets from the primary carrier and all medical bills incurred while on your trip from your

other insurance in the form of standard UB and HCFA billing statements.

3 Completed and signed claim form

3 Copy of rental agreement

3 Credit card statement, cancelled checks, or cash receipt for all medical payments while on your trip

3 If Claimant is other than leaseholder, please provide a signed written statement from leaseholder listing all guests

occupying the rental property.

Claimed Expenses

_________________ Total amount paid for all medical treatment received while on trip (Attach all invoices)

_________________ Total amount reimbursable from other sources (Attach all responses received)

_________________ Total amount being claimed from Red Sky

Authorization to Disclose Information

Trip Preserver Product is Underwritten by Arch Insurance Company.

To any medical care provider, medical care facility, Insurer, government-sponsored health plan, or employer: I authorize the release of any

medical information about me to Arch Insurance Company, or its authorized representative. This applies to all information about the diagno-

sis, treatment, or prognosis of any illness or injury I now have or have had in the past. The Company will use this information to determine if

my claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance carrier (if any) or

persons or organizations performing investigative or legal services for the Company in connection with my claim. A copy of this authorization

shall be considered as eect and valid as the original and shall remain in eect for one year from the date of authorization. I certify that the

information given by me in support of my claim is true and correct.

Patient’s or Authorized Representative’s Signature Date

If Authorized Representative, Relationship to Patient

or Legal Designation

Assignment of Benets

I Authorize the Claims Administrator, to pay benets in connection with this claim directly to the doctor, hospital, or other provider.

Patient’s or Authorized Representative’s Signature Date

If Authorized Representative, Relationship to Patient

or Legal Designation

Arch-2014

The laws of some states require us to furnish you with the following notices:

WARNING. Any person who knowingly:

Alaska: and with intent to injure, defraud, or deceive an insurance company les a claim containing false, incomplete, or misleading information

may be prosecuted under state law.

Arizona, Arkansas and Rhode Island: presents a false or fraudulent claim for payment of a loss or benet is subject to criminal and civil pen-

alties, or specic to AR and RI: presents false information in an application for insurance is guilty of a crime and may be subject to nes and

connement 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 payment of a loss is guilty of a crime and may be subject to nes and conne-

ment in state prison.

Delaware: and with intent to injure, defraud or deceive an insurer, les a statement of claim containing any false, incomplete or misleading infor-

mation is guilty of a felony.

District of Columbia: 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 nes. In addition, an insurer may deny insurance benets if false information materially related to

a claim was provided by the applicant.

Florida: and with intent to injure, defraud, or deceive any insurance company, les a statement of claim containing any false, incomplete, or

misleading information is guilty of a felony of the third degree.

Idaho and Indiana: and with intent to defraud or deceive any insurance company, les a statement of claim containing any false, incomplete or

misleading information (for Idaho) is guilty of and (for Indiana) commits a felony.

Kentucky, New York, and Pennsylvania: and with intent to defraud any insurance company or other person les an application for insurance,

or les a statement of claim, containing any materially false information or conceals, for the purpose of misleading, information concerning any

material fact thereto commits a fraudulent insurance act, which is a crime, specic to PA: subjects such person to criminal and civil penalties and

specic to NY: shall also be subject to a civil penalty not to exceed ve thousand dollars and the stated value of the claim for each such violation.

Louisiana, New Mexico, Texas and West Virginia: presents a false or fraudulent claim for the payment of a loss (or specic to LA, TX and WV: who

knowingly presents false information on an application for insurance) is guilty of a crime and may be subject to nes and connement in state

prison, (or specic to NM: to civil nes and criminal penalties.)

Maryland: and willfully presents a false or fraudulent claim for payment of loss or benet or who knowingly and willfully presents false informa-

tion in an application for insurance is guilty of a crime and may be subject to nes and connement in prison.

New Jersey: les a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Ohio: with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits and application or les a claim containing a false

or deceptive statement is guilty of insurance fraud.

Oklahoma: 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: and with intent to defraud any insurance company or other person les 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 hereto, may be subject to

prosecution for insurance fraud.

Puerto Rico: and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the pre-

sentation of a fraudulent claim for the payment of a loss or any other benet, 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 ne of not less that ve thousand (5,000) dollars

and not more than ten thousand (10,000) dollars, or a xed term of imprisonment for three (3) years, or both penalties. If aggravating circum-

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

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

WARNING:

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, nes, denial of insurance and civil damages. Any insur-

ance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyhold-

er or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable

form insurance proceeds shall be reported to the Colorado Division of Insurance withing the Department of Regulatory Agencies.

Hawaii: Presenting a fraudulent claim for payment of a loss or benet is a crime punishable by nes or imprisonment, or both.

Maine/Washington: It is a crime to knowingly provide false, incomplete or misleading information ton an insurance company for the purpose of

defrauding the company. Penalties may include imprisonment, nes or a denial of insurance benets.

Minnesota: A person who les 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 the purpose to injure, defraud or deceive any insurance company, les 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.

Tennessee and Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurer or insurance company for

the purpose of defrauding the insurer or insurance company. Penalties include imprisonment, nes and denial of insurance benets.

Fill Online, Printable, Fillable, Blank Primary Medical Expense Claim Form (Trip Preserver online claims) Form

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Fillable Primary Medical Expense Claim Form (Trip Preserver online claims)

Fill Online, Printable, Fillable, Blank Primary Medical Expense Claim Form (Trip Preserver online claims) Form

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