Jrotc Insurance Form - Elkin City Schools
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NOTIFICATION OF INJURY
United States Fire Insurance Company
_____________________________________
This Notification of Injury Form is to be used for accident medical claims. This form and all other correspondence must be
submitted within 90 days from the date of accident.
Policies With Excess Coverage
Eligible covered expenses will be paid only if they are in excess of other valid and collectible insurance or medical payment
plan. If the claimant is covered by any other health insurance or medical payment plan they must first submit claim to the
primary insurance. After the primary insurance has paid benefits, then submit this claim form along with all EOB’s
(explanation of benefits) from the primary insurance.
Policies With Primary Coverage
Eligible covered expenses will be paid regardless of other valid and collectible insurance or medical payment plan. There is no
need to submit claim to any other insurance.
Claim Form
This Company claim form must be submitted for each individual claim. Part (A) must be completed in full by the Policyholder
official or a staff member and signed by the Policyholder official or staff member. Part (B) must be completed in full by the
injured person or the parent or guardian if that injured person is a minor and also must be signed. A fully completed claim
form is not necessary when submitting additional medical bills; only one claim form is needed per accident/injury.
Medical Bills
Attach all medical bills. All submitted medical bills must be itemized for service. A balance due statement is not acceptable
and will only delay processing. A physician’s office should submit an invoice per CMS 1500. A hospital and/or emergency
room should submit an invoice per UB04. CMS 1500 and UB04 are universal billing forms supplied by the physician’s office
and/or hospital.
Information Requests
In the event that a claim is not submitted in full or if additional information is needed, the claim will be closed, and the
additional information will be requested via US Mail. Please forward the requested information immediately, so that we may
finish adjudicating your claim in a swift manner. The explanation of benefits (information request) will be sent to the address
of the injured person listed on the claim form in Part (B).
Claim Submission Checklist
Use the below checklist to assure a properly submitted medical claim is to be sent.
If the injured person has primary health insurance has the claim been submitted first to the primary
Yes
No
health insurance company?
If claim has first been submitted to the primary health insurance company, are copies of EOB’s
Yes
No
(explanation of benefits) attached?
Yes
No
Is part (A) of the claim form completed by the Policyholder official or staff member and signed?
Yes
No
Is part (B) of the claim form completed by the injured person and signed?
Yes
No
Are the attached medical bills itemized in either a CMS 1500 or UB04 form?
Yes
No
Is part (B), item number 3 (social security number) completed?
Form Number USFIC FLD 2011
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