Girl Scouts Of The Usa Claim Form printable pdf download

GIRL SCOUTS OF THE U.S.A.

CLAIM FORM

Mail any additional bills

Special Risk Services

➧

(properly identified by

United of Omaha Life Insurance Company

injured person and

P.O. Box 31156

Council name) to:

Omaha, Nebraska 68131

1-800-524-2324

CLAIMANT INFORMATION — ALL QUESTIONS MUST BE ANSWERED

Claim is made under the following Plan:

___ Plan 1 – Basic Coverage

Enrollment Request ID: __________________________

(Applicable to Optional Coverages only)

___ Plan 2 – Participant Accident

___ Plan 3E – Extended Event

___ Plan 3P – Extended Event

___ Plan 3PI – International Extended Event

___ International Inbound

Name of claimant

Identification Number

Age

Date of Birth

Claimant’s address

Number and Street

City

State

ZIP Code

If claimant is a minor, name of parent or guardian

Phone Number

(

)

Address of parent or guardian

Number and Street

City

State

ZIP Code

If your organization has selected coverage containing a Nonduplication amount, the benefits will be considered as follows: The Nonduplication amount, as stated

in your selected coverage, of medically necessary services and supplies can be paid regardless of other insurance coverage. For expenses over the Nonduplication

amount, or if you expect the total to exceed the Nonduplication amount, you must submit to your primary insurance carrier. We require their Explanation of payment

even if it is applied to your deductible. If Denied, send a copy of your denial notice. Include itemized bills.

Father, Guardian or Claimant’s (if adult) Employer’s Name and Address:

_________________________

Phone No. ( _______ ) _______ - __________

Mother, Guardian or Spouse’s Employer’s Name and Address:

_________________________

Phone No. ( _______ ) _______ - __________

Name of all companies providing your insurance coverage or prepaid health plans.

Name of Company

Address

Policy or Certificate No.

__________________________________________________________________________________________________________________________________________

If you do not have other coverage, sign and date the following statement.

I, _____________________________________________ , on_______________________ , verify there is no other insurance coverage available for these and all

expenses related to this claim.

I hereby certify that all above information is true and complete.

I verify that I have read and understand the fraud statement for my state that accompanied this form.

_____________________________________________________________________________

_____________________________________

Signature (Parent/Guardian)

Date

GIRL SCOUT LEADER STATEMENT

■

Daisy

Cadette

Nonmember Child