Form M18979 - Girl Scouts Of The U.s.a. Claim Form

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Girl Scouts of the U.S.A. Claim Form
Mail any additional bills (properly identified by injured person and
Council name) to:
Special Risk Services
P.O. Box 31156
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.
New York Claimants: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR
INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION
CONCERNING ANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT
TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. (PURSUANT TO 11 NYC RR86)
_____________________________________________________________________________
_____________________________________
Signature (Parent/Guardian)
Date
ATTACH ITEMIZED BILLS WITH A DOCTOR’S DIAGNOSIS
M18979_0515

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