Insurance Claim Form - United States Fire Insurance Company printable pdf download

UNITED STATES FIRE INSURANCE COMPANY

By Fairmont Specialty, a Division of Crum & Forster

Eatontown, New Jersey

Claim Instructions

*Attach itemized bills, showing treatment, and dates of treatment

MAIL TO:

and charges to the claim form, forward additional bills to the

above address

Do not leave claim form at hospital.*Payment

T.W. LORD & ASSOCIATES

Will be made to the doctor or hospital, etc., unless a paid receipt

P.O. BOX 1185

or statement is attached.* No additional claim form is necessary.

MARIETTA, GA 30061

PHONE 1-800-633-2360

It is a crime to provide false or misleading information to an insurer for the purpose 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.

=======================================================================================================

To Be Completed By Claimant

SOCIAL SECURITY NUMBER

__________________________________________________________________________________________________-______-

Claimant’s Name_____________________________________________________________Date of Birth__________Male_____Female______

Last Name

First Name

Present Address_______________________________________________________________________________________________________

No. & Street

City or Town

State

Zip

Dependent’s Name_________________________________Phone Number_____________________email address______________________

========================================================================================================

Date of accident or sickness

___________________________________________If Pregnant state Last Menstrual Period Date___________________________

Nature of sickness or injury

_________________________________________________________________________________________________________

If injury, describe fully how and

If Injured in Play or Practice of Sport

where accident occurred

Indicate What Sport

Check One: ____Intramural ___ Inter Collegiate____Club

_____________________________________________________________________________________________________________________

Have you ever had the same

___ Yes

Were you treated at the Student Health Services?

or similar symptoms

___ No

If so, when?

_____Yes

_____No

If so, When? And attach documentation

_____________________________________________________________________________________________________________________

Name and Address of Physician

_____________________________________________________________________________________________________________________

Give names of all other

Physicians consulted

_____________________________________________________________________________________________________________________

Hospitalized

From:

To:

____________________________________________________________________________________________________________________

Name and Address of Hospital

____________________________________________________________________________________________________________________

Are you covered by any other medical insurance policy? Yes_____ No_____ if Yes, Please provide name and address of other Insurance Company.

____________________________________________________________________________________Policy Number:___________________________________

____________________________________________________________________________________________________________________________________

AUTHORIZATION TO OBTAIN MEDICAL INFORMATION

TO: Any medical professional, hospital or other medical-care institution, insurance support organization, pharmacy, governmental agency,

insurance company, group policyholder or benefit plan administrator.

I AUTHORIZE you to release to the UNITED STATES FIRE INSURANCE COMPANY or its representatives, PROFESSIONAL CLAIMS

ADMINISTRATORS, INC. any and all information concerning advice, care or treatment provided the patient, or deceased, including information

relating to mental illness, use of drugs or use of alcohol. I also authorize the group policyholder or benefits plan administrator to provide to the

UNITED STATES FIRE INSURANCE COMPANY or its representatives, PROFESSIONAL CLAIMS ADMINISTRATORS, INC. with

insurance coverage information including benefits paid or payable, financial information or employment related information. I UNDERSTAND

that the information released under this authorization will be used for the purpose of evaluating and processing a claim for benefits. I authorize the

UNITED STATES FIRE INSURANCE COMPANY, or its representatives, PROFESSIONAL CLAIMS ADMINISTRATORS, INC. to disclose

the information for that purpose to the group policyholder or its representatives, to any reinsurer, and to any other insurer or self-insurer to whom a

claim for benefits may be submitted. This disclosure will include benefits paid or copies of checks/drafts.

I also AUTHORIZE the UNITED STATES FIRE INSURANCE COMPANY, or its representatives, PROFESSIONAL CLAIMS

ADMINISTRATORS, INC. to disclose the information to any person performing a business or legal function for its benefit, and to any person

who has an authorization specifically permitting the disclosure.

I AGREE that the authorization shall be valid from the date signed for one full year.

I know that I have a right to request to receive a copy of this authorization. A photocopy of this authorization shall be as valid as the original.

____________________________________________________________________

_________________________________

Signature of Patient

Date Signed

Insurance Claim Form - United States Fire Insurance Company

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