Student Accident Claim Forms

Please note that bills must be sent to the company identified within 90 days of the date of service, with the claimants name, policy number, school district (if applicable) and date of Accident. Please follow the instructions below to file a claim.

Completion of a claim form does not guarantee benefit payment. Each claim is reviewed according to policy provisions.

Your Student's been Injured

Your student has been injured and you need to file a claim. Simply select your State and click on Lookup. Select your school or district from the listings shown on the right. The click on the claim form link and print the form.


Claim Filing Instructions

ALL INFORMATION MUST BE PROVIDED IN ORDER FOR CLAIM TO BE PROCESSED
  • Obtain claim form through above instructions, from your marketing agent, Organization or School and answer all questions in detail (including all required signatures). A claim form needs to be completed for each accident. Print or type clearly on the claim form and try to refrain from using abbreviations for your city or county. Be specific in your description of what happened.
  • If you have other insurance, submit your claim to your other insurer. When you receive the explanation of benefits notice from your primary carrier, send it to the address on the claim form along with the corresponding itemized bills and fully completed claim form. You must submit itemized bills; balance due statements will not be processed. Itemized bills include:
            1) HCFA-1500 (standard form used by Providers)
            2) UB-04 or UB-92 (standard form used by Hospitals)
  • If you already paid the bill, include a paid receipt or a copy of your cancelled check. Otherwise payment will be made to the providers of service (Hospital, Physician or Others), unless a paid receipt statement accompanies the bill at the time the claim is submitted.
  • Send all correspondence to the address on the claim form. The claim form must be sent within 90 days of the date you first received medical care. Any itemized bills, explanation of benefits or paid receipts not filed with the original claim form should be sent, within 90 days of the date you received medical care, to the claim office identified with the claimant’s name, policy number, school district or organization and date of Accident.
  • If you change your address, please notify the claim office by calling the number on the claim form so that there is no delay in processing any claims.
  • Please contact the claim office by calling the number on the claim form if you would like to check the status of your claim or if you have any questions on how your claim was processed or the benefit paid. Please allow 15 business days before calling to the check the status of your claim.
KEEP COPIES OF ALL CLAIM FORMS, BILLS, AND CORRESPONDENCE FOR YOUR OWN RECORDS UNTIL YOUR CLAIM HAS BEEN PROCESSED.