Accident Report Form Page 4
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4000168139/ JSX0000026518100
OTHER INSURANCE
QUESTIONNAIRE
m
m
Yes
No
NAME OF CLAIMANT:______________________________________________________________________ INTERNATIONAL STUDENT
m
Yes
m
No
m
Yes
m
No
EMANCIPATED STUDENT:
OVER AGE 26 AND NO LONGER DEPENDENT ON PARENT:
NAME OF INSURED:____________________________________________________ POLICY NO: _____________________________________________
FATHER
MOTHER
m
m
m
m
Yes
No
Yes
No
IS FATHER DECEASED?
IS MOTHER DECEASED?
m
m
m
m
Yes
No
Yes
No
IS FATHER LEGALLY RESPONSIBLE?
IS MOTHER LEGALLY RESPONSIBLE?
FATHER’S NAME (if injured is a minor) _______________________________
MOTHER’S NAME (if injured is a minor) ______________________________
SOCIAL SECURITY #: ___________________________________________
SOCIAL SECURITY #: ___________________________________________
m
m
m
m
m
m
m
m
Yes
No
Yes
No
Yes
No
Yes
No
EMPLOYED?
SELF-EMPLOYED?
EMPLOYED?
SELF-EMPLOYED?
m
m
m
m
Yes
No
Yes
No
DISABLED ON MEDICAID OR OTHER PUBLIC ASSISTANCE?
DISABLED ON MEDICAID OR OTHER PUBLIC ASSISTANCE?
EMPLOYER NAME: _____________________________________________
EMPLOYER NAME: _____________________________________________
EMPLOYER ADDRESS: __________________________________________
EMPLOYER ADDRESS: __________________________________________
CITY:_________________________ STATE:_______ ZIP: ______________
CITY:_________________________ STATE:_______ ZIP: ______________
PHONE: (______) _____________________________________________
PHONE: (______) _____________________________________________
CONTACT PERSON: ____________________________________________
CONTACT PERSON: ____________________________________________
Do you have group medical insurance coverage through your employment?
Do you have group medical insurance coverage through your employment?
m
m
m
m
Yes
No
Yes
No
If no, please be advised K&K may contact your employer to verify no primary
If no, please be advised K&K may contact your employer to verify no primary
insurance is in force.
insurance is in force.
INSURANCE COMPANY: __________________________________________
INSURANCE COMPANY: __________________________________________
INSURANCE COMPANY ADDRESS: __________________________________
INSURANCE COMPANY ADDRESS: __________________________________
CITY:_________________________ STATE:_______ ZIP: ______________
CITY:_________________________ STATE:_______ ZIP: ______________
POLICY NUMBER: ______________________________________________
POLICY NUMBER: ______________________________________________
m
m
TYPE OF PLAN:
HEALTH MAINTENANCE ORGANIZATION (HMO)
TYPE OF PLAN:
HEALTH MAINTENANCE ORGANIZATION (HMO)
m
m
PREFERRED PROVIDER ORGANIZATION (PPO)
PREFERRED PROVIDER ORGANIZATION (PPO)
m
m
STANDARD MEDICAL AND HOSPITALIZATION COVERAGE
STANDARD MEDICAL AND HOSPITALIZATION COVERAGE
m
m
OTHER (describe) ____________________________
OTHER (describe) ____________________________
I/WE AGREE THAT ALL INFORMATION PROVIDED IN THIS DOCUMENT IS ACCURATE AND COMPLETE TO THE BEST OF MY/OUR KNOWLEDGE. I/WE
UNDERSTAND THAT ANY INCORRECT OR UNDISCLOSED INFORMATION CAN RESULT IN DUPLICATE PAYMENTS CREATING A SUBSTANTIAL OVERPAYMENT. THE
RESPONSIBILITY OF SUCH OVERPAYMENT WILL BE THE OBLIGATION OF THE UNDERSIGNED TO REIMBURSE IN FULL, UPON REQUEST, ALL AMOUNTS DEEMED
REFUNDABLE. I UNDERSTAND THAT IT IS A CRIME TO INTENTIONALLY ATTEMPT TO DEFRAUD OR KNOWINGLY FACILITATE A FRAUD AGAINST AN INSURER
BY FILING INFORMATION CONTAINING FALSE OR DECEPTIVE STATEMENTS. ANY QUESTIONS ON THIS FORM NOT ANSWERED TRUTHFULLY CAN RESULT IN A
CRIME.
PARENT/GUARDIAN/FATHER SIGNATURE:____________________________________ PARENT/GUARDIAN/MOTHER SIGNATURE:_______________________________________
DATE:_________________________________
DATE:_________________________________
1638 7/11
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