Jrotc Insurance Form - Elkin City Schools Page 2
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4Mailing The Claim
When completed in full, mail the attached completed claim form, itemized medical bills and copies of EOB’s (explanation of
benefits for use if coverage is excess) to:
The Loomis Company
P.O. Box 14162
Reading, PA. 19612-4162
If you should have any questions, or if a physician’s office or hospital needs to confirm benefits before a medical procedure,
please contact the claims office at (866) 915-6618.
Documents may also be faxed to the claims office at (610) 370-6767. Please do not fax full medical claims, as often times
medical bills are illegible when faxed. For emailing documents, please email
PLEASE NOTE: Claims Must Be Submitted Within 90 Days Of The Date Of Accident.
NOTICE
Fraud Warning: Any person who, with the intent to defraud or knowingly facilitates a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement, or conceals
information for the purpose of misleading may be guilty of insurance fraud and subject to criminal and/or
civil penalties.
PART A – This PART MUST be completed, dated and signed by an official or the Organization.
1. Name of Organization and Policy Number
2. Address of Organization
(Street)
(City)
(State)
(Zip)
3. Name of Injured Person (Insured)
(First)
(Middle)
(Last)
4. Date of Accident/Injury
5. Injury Occurred:
6. Type of Sport or Activity:
□
□
□
Mo
Day
Year
Practice
Travel
Game
/
/
Other ____________________________________
7. Explain HOW the accident and injury occurred. NOTE: If your organization uses an Accident Report form, attach a copy of the Report.
7b. Please indicate body part injured:
8. At the time of the accident, was the Injured Person
9. Name of Supervisor of Activity
10. Was he/she a witness to
□
□
involved in an activity under the jurisdiction of the
Yes
No
□
□
Organization (Policyholder)? Yes
No
11. Signature of Organization Official
12. Title of Official
13. Area Code/Telephone No.
14. Date Signed
(
)
X
________________________________________
Form Number USFIC FLD 2011
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