R&I E-07 101919 Page 1 of 2
Questionnaire to Determine Third-Party Liability
To determine benefits for claims that may be the result of an injury or illness involving a third party, HMAA requires the following information
for any related services. All questions require a response. If additional space is required, please attach a sheet. Upon completion, please
sign and date this form, then return all pages to HMAA via fax or mail. Make sure to retain a copy for your records. Failure to respond may
result in the denial of your claims. If you have any questions, please contact our Customer Service Center at the phone numbers shown
HMAA Claims Department, Fax (808) 535-8357
Name of Insured/Subscriber
Name of Patient
Member ID Number
Date(s) of Service
Diagnosis or Brief Description of Injury/Illness (example: broken arm)
General Information
I. Please provide exact details on the injury/illness that occurred:
1. DATE it happened: 2. WHERE it happened: Work Home Other:
3. HOW it happened:
II. Have you hired an attorney or retained legal counsel to represent you in connection with this injury/illness?
No, but I plan to. No, and I do not plan to.
Yes - Name and address of your attorney or legal counsel:
III. Was a police report made? No Yes Submit a copy of the police report.
Related to Work
IV. Was the injury/illness related to work? No Yes Answer this section.
1. Name of your Employer:
Phone Number and/or Address:
2. Have you filed for Workers’ Compensation?
No Explain:
Yes Provide the following information:
a. Has your case been settled? Yes Submit a copy of the settlement document
No, the current status is: _________________. Submit a copy of your claim and other reports.
b. Name of Insurance Company covering your Workers’ Compensation claim:
Involves a Motor Vehicle
V. Did the injury involve a motor vehicle? No Yes answer this section and submit a copy of your insurance recap
sheet and other information from your insurance carrier.
1. What involvement did you have in the accident?
Driver Name and phone # of vehicle’s owner:
Passenger Name and phone # of vehicle’s owner:
Pedestrian Name and phone # of vehicle’s owner that struck you:
2. Name of the Insurance Company and Policy Number which insured the vehicle involved:
Phone Number and/or Address:
3. Are no-fault benefits available for this accident?
No Explain:
Yes Indicate your policy limit: $____________.
Continued on next page. Both pages must be completed.
737 Bishop Street, Suite 1200
Honolulu, Hawaii 96813
Phone (808) 941-4622 / Toll-Free (888) 941-4622
R&I E-07 101919 Page 2 of 2
Another Person(s) Is or May Be Responsible
VI. Is another person(s) potentially responsible for your injury/illness? No Yes Answer this section.
1. Name of Person(s) you believe could be responsible:
Phone Number and/or Address:
2. Date on which you determined that the person(s) could be responsible:
3. Did you make a written claim or demand, file a lawsuit, or initiate any legal action against the person(s) in
connection with your injury/illness?
No, but I plan to. No, and I do not plan to. Explain:
Yes Provide the following information:
a. Have you received any money from another source as a result of your injury/illness?
No, but I plan to. No, and I do not plan to. Explain:
Yes Name of source:
b. Has your claim, demand, and/or action been settled?
No, the current status is: _________________. Submit a copy of your claims, demands,
and/or complaints that you have made or were made on your behalf.
Yes Submit a copy of the settlement document and provide the following information:
i. Date of settlement: ii. Settlement amount:
iii. Name of person/carrier you received amount from:
Agreement Between You and HMAA
Please read the following carefully. If someone else caused or may have caused your injury or illness, HMAA will pay Plan benefits to
the extent provided in your HMAA Plan pursuant to Sections 431:13-103(a)(10) and 663-10(b)(1) of the Hawaii Revised Statutes,
conditioned on your satisfaction of the following:
GIVING HMAA TIMELY WRITTEN NOTICE, within 30 days after the occurrence of any potential claim or demand made against
any third party or source of recovery;
SIGNING REQUESTED DOCUMENTS HMAA provides to you to secure its lien and reimbursement rights, including but not
limited to, this agreement;
PROMPTLY PROVIDING HMAA INFORMATION it further requests related to its investigation of HMAA’s liability for coverage
and its determination of its rights to recover payments; and
COOPERATING WITH HMAA regarding its reimbursement rights, and giving notice of HMAA's lien in any written claim or
demand for recovery for your illness or injury.
I further understand and agree:
A. My failure to comply with Sections 431:13-103(a)(10) and/or 663-10(b)(1) of the Hawaii Revised Statutes may result in delay in
payment and/or denial of my claims, and will entitle HMAA to reimbursement of its payments to the extent my failure to cooperate
has resulted in erroneous payments of benefits or has prejudiced HMAA’s rights to recovery of payments.
B. Medical expenses that may be covered by worker's compensation are excluded from coverage under my HMAA Health Plan
and will not be paid by HMAA.
C. For medical expenses that may be covered under motor vehicle personal injury protection (PIP) insurance, PIP must pay and be
exhausted before any coverage under the HMAA Plan will apply.
D. If the injury or illness is to an Eligible Dependent ("Dependent") under my HMAA Health Plan, the promises in this Agreement
bind both me and my Dependent and apply to any recoveries received due to the Dependent's injury or illness.
I acknowledge that the answers in this questionnaire are true and complete to the best of my knowledge, and that I have carefully
read the Reimbursement Agreement and agree to comply with and be bound by its provisions.
Insured Name (print) Signature Date
Patient Name (print) Signature (if 18 or older ) Date
If signed by someone other than the patient, indicate relationship to patient:
Please return this entire completed form to HMAA via mail, or fax to (808) 535-8357.