Fillable TRAVEL-MEDICALEXPENSE CLAIM FORM C&F and Crum & Forster (University of South Florida)

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TRAVEL-MEDICALEXPENSE CLAIM FORM C&F and Crum & Forster (University of South Florida)

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The TRAVEL-MEDICALEXPENSE CLAIM FORM C&F and Crum & Forster (University of South Florida) form is 2 pages long and contains:

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  • 14 check-boxes
  • 40 other fields

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TRAVEL-MEDICALEXPENSE
CLAIM FORM
C&F and Crum & Forster are registered trademarks of United States Fire Insurance Company.
Note: Travel insurance products sold by UnitedHealthcare Global are underwritten by United States Fire Insurance Company. Please
complete this form to make a medical expense insurance claim.
SECTION 1: INSURED AND TRAVEL INFORMATION
Name of Insured Policy Number Home Phone Cell phone
__________________________________________
Street Address City State Zip Code
Travel Agency/Tour Operator/Cruise Line Agent Name Phone Number Booking/Reservation #
Destination(s)
Name(s) of all travelling companions:
Scheduled Departure Date City of Departure
Scheduled Return Date Return Destination
SECTION 2: OTHER INSURANCE INFORMATION
Do you have any other health or medical insurance? Yes No If yes. Please complete the following:
Name of Insurance Company Policyholder Name / Relation Policy No. Insurance Co. Phone #
___________________________________
Supplemental Insurance Company Policyholder Name / Relation Policy No. Insurance Co. Phone #
____________________________________
Has a claim been filed with your Insurance Company? Yes No If yes, please provide a copy of the company’s
corresponding Explanation of Benefits for any bills you are requesting benefits for. If no, please submit the bill to your Insurance
Company and provide us with a copy of the company’s corresponding Explanation of Benefits
SECTION 3: DETAILS OF SICKNESS / INJURY
Date Sickness or Injury began: Date of first treatment:
Nature of sickness / details of accident:
Have you ever been treated for this condition previously? Yes No Date(s) of treatment(s):
Name, address and phone number of treating physician(s):
(1) Physician’s Name: Phone:
Address:
(2) Physician’s Name: Phone:
Address:
TMED-1016 / page 1 of 2
TRAVEL-MEDICAL EXPENSE
CLAIM FORM
C&F and Crum & Forster are registered trademarks of United States Fire Insurance Company.
Note: Travel insurance products sold by UnitedHealthcare Global are underwritten by United States Fire Insurance Company. Please
complete this form to make a medical expense insurance claim.
NEW YORK FRAUD WARNING: 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.
AUTHORIZATION: I hereby authorize Crum & Forster, United States Fire Insurance Company or its representative, to inspect or
secure copies of case history records or any other data necessary to determine eligibility of benefits. I also authorize Crum & Forster,
United States Fire Insurance Company or its representative to release and share claim information including that which may be used in
the identification and prevention of potential fraudulent activity to any insurance organization, fraud information clearinghouses,
designated service providers and business associates assisting in the processing of this claim. A photostatic copy or facsimile of this
authorization shall be deemed as effective and valid as the original. This authorization is valid for twelve (12) months from date of
signature. I HAVE REVIEWED AND ACKNOWLEDGE THE ATTACHED FRAUD WARNING.
SIGNATURE OF INSURED DATE
CLAIM DOCUMENTATION REQUIREMENTS:
Depending upon the circumstance involved in the loss, one or more of the following items may be required to complete the processing
of your claim. Please place a check by those items you have attached. We recommend you keep copies of any items submitted with
this claim.
Copies of itemized bills and/or statement from medical providers for services rendered in connection with your claim. These bills
and/or statements must include the date of service, the service rendered, the charge for each service, and the diagnosis
If you have other insurance, we need the final disposition from the primary insurer listing payment or denial of your claim with them
(Explanation of Benefit or “EOB”).
Copies of the front and back of your cancelled checks and/or your credit card statements showing your payments for the trip; and a
copy of your trip invoice.
Airline Ticket Stub/Receipt (if applicable)
Copies of your credit card statements and/or cancelled checks showing your payment for the medical service submitted
If medical expenses were incurred abroad, attach copies of your passport pages which identify you as the traveler and document
your entrance into and exit from the country or countries where medical services were received
Other (please describe):
Please advise if you wish to be contacted via e-mail or regular mail
PLEASE COMPLETE THIS FORM IN FULL AND RETURN TO:
Claims and Correspondence Mailing Address: Travel Insurance Claims
P.O. Box 20874
Tampa, FL 33622
Travel Claims and Customer Care Email Address: TravelTeam@cbpinsure.com
Customer Care Phone Number: 877-693-8530
Toll Free Fax #: 800-560-6340
Direct Dial Fax #: 727-499-7578
T MED-1016 / page 2 of 2
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Page 1 of 2 CF010117
CLAIM FORM FRAUD STATEMENT - 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.
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.
ALASKA: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
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 fins 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.
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.
IDAHO: Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement of
claim containing any false, incomplete, or misleading information is guilty of a felony.
KANSAS: 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 may be guilty of insurance fraud as determined by a court of law
and may be subject to fines and confinement in prison.
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 information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime
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 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.
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: 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.
TENNESSEE: 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.
Page 2 of 2 CF010117
CLAIM FORM FRAUD STATEMENT - continued
TEXAS: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may
be subject to fines and confinement in state prison.
VIRGINIA: Any person who, with the 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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TRAVEL-MEDICALEXPENSE CLAIM FORM C&F and Crum & Forster (University of South Florida)

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Completed 29 July 2020

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