Claim Form

Part A:
Name of Policy Holder:*
   
Policy Number:*
       
Athlete Name:* Date of Birth (12/12/2012):* Sex:* Social Security No. (123-12-1234):*
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Athlete Address:* City:* State:* Zip:*
       
Phone (123-123-1234):* Email (if available):    
   
 
Part B:
Date of Injury*    
 
Select the Competition (check one only):*
Band
Baseball
Basketball
Bowling
Cheerleading
Cross Country
Dance/Drill Team
Equestrian
Football, Tackle (Fall)
Football, Tackle (Spring)
Football, Touch/Flag
Golf
Gymnastics
Hockey, Field
Hockey, Ice
Lacrosse
Rodeo
 
Rugby
Soccer
Softball
Student Coaches
Student Managers
Student Trainers
Swimming / Diving
Tennis
Track & Field (Indoor)
Track & Field (Outdoor)
Volleyball
Water Polo
Wrestling
Other (List Below)
 
 
Injury Occurred during (check one only):*
Practice
Game
Conditioning
Group Travel
 
Individual Travel
Other (List Below)
 
 
Body Part Injured (check all that apply):*
  Right Left
Finger
Hand
Wrist
Elbow
Arm
Shoulder
Head
Toe
Foot
Ankle
Knee
Leg
 
  Right Left
Hip
Groin
     
Neck
Head
Back
Abdomen
Chest
Other (List Below)
   
 
Explain how the accident and injury occurred or attach a copy of the completed accident report:*
 
Attach a file:
 
Description:
 
Part C:
Is the athlete eligible to receive benefits under governmental plan or program, including Medicare?*
yes no
Is the athlete covered under any other health and / or accident insurance plans?*
yes no
   
If the athlete is under age of 26 or otherwise dependent, complete the following information:
Name of Father or Guardian:
Social Security No.:
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Place of Employment:
Address of Employer:
Employer Phone Number:
   
Name of Mother or Guardian:
Social Security No.:
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by an encrypted connection.
Place of Employment:
Address of Employer:
Employer Phone Number:
   
If the insured person is married, complete the following information:
Name of Spouse: 
Social Security No.:
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by an encrypted connection.
Place of Employment:
Address of Employer:
Employer Phone Number:
 
Part D:
At the time of the incident, was the injured person involved in a sponsored / supervised activity of the policyholder?*
yes no
   
Name and Title of Official completing form:*
Email:*
Contact Phone Number (123-123-1234):*
Send a confirmation email to the email address above:
 

FRAUD STATEMENTS

If you live in a state other than mentioned below, the following statement applies to you:
Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, files a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties.  In addition, any insurer or insurance company may deny benefits if false information materially related to a claim is provided by the claimant.

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.

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, Rhode Island and West Virginia:  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.

Delaware:  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 purposes 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: 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.

Indiana:  A person who knowingly and with intent to defraud an insurer, files a statement of claim containing any false, incomplete, or misleading information, commits a felony.

Kentucky:  Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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.

Maine, Tennessee, Virginia and Washington:  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.

Maryland:  Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Minnesota:  A person who files 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 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 includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New Mexico:  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 CIVIL FINES AND CRIMINAL 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.

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.

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.