Group Accident Claim Form - Obu Home - 2014
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1
2Group Accident Claim Form
Send to Guardian Life Insurance, Accident Claims, PO Box 14315, Lexington, KY 40512
Customer Service: 1-800-541-7846
Fax: (920) 749-6299
Documents can be returned electronically at Click on “Secure Channel” on the Guardian Anytime home page.
EMPLOYEE INFORMATION
1. Employee’s Name:
2. Plan Number:
3. Date of Birth:
4. Social Security #:
5. Gender:
6. Marital Status:
Male
Female
7. Employee’s Address:
8. Employee email address (optional):
9. Preferred Telephone Number:
Complete this section, if the claim is for a dependent. Otherwise, proceed to the claim information section.
DEPENDENT INFORMATION
10. Dependent’s Name:
11. Dependent’s Preferred Telephone
12. Dependent’s Date of Birth:
Number:
13. Gender:
14. Relationship to the employee:
15. Dependent’s Social Security Number:
Male
Female
FIRST CLAIM
CONTINUED CLAIM
ACCIDENT
HOSPITAL CONFINEMENT (SICKNESS) *Separate Rider Required
CLAIM INFORMATION SECTION
If you have incurred an accident, please check the box or boxes that best describe your current Accident Claim. Attach any documentation you may
have indicating the provider, patient’s name, copy of itemized billing statement, date of service and if filing for the fracture benefit, a copy of the
radiology report.
Fracture (Bone)/Dislocation/Surgery
Hospital Admission/Confinement (Accident)
Medical Expenses
Ambulance Services:
Ground Ambulance
Air Ambulance
Organized Sport – Submit Proof of Participation
Transportation or Lodging
Other: Explain ____________________________________________________________________________________________________
DATE OF ACCIDENT: _____ /_____ /_____ TIME OF ACCIDENT: _______
AM
PM
Was Accident Work Related?
Yes
No
Where did Accident Happen? _____________________________________________________________________________________________
Was a Police Report filed?
Yes
No
if yes, please attach a copy of the report.
Tell us how your accident/injury happened:
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
PATIENT INFORMATION
I authorize any physician, medical practitioner, hospital, clinic, other health facility, consumer reporting agencies, the Medical Information Bureau,
insurance or reinsurance company, or employer to release any and all medical and non-medical information about me in its possession to The
Guardian Life Insurance Company of America or its legal representatives. Medical information means all information in the possession of or derived
from providers of health care regarding my medical history, mental or physical condition, or treatment. I understand that Guardian will use the
information obtained by this authorization to determine eligibility for insurance or eligibility for benefits under an existing plan. Guardian will not
release any information obtained to any person or organization except to reinsurance companies, the Medical Information Bureau, or other persons
or organizations performing business or legal services in connection with my application, claim, or as may be lawfully required or permitted, or as I
may further authorize. I know that I may request and receive a copy of this authorization. I agree that a photocopy of this authorization shall be as
valid as the original. I agree that this authorization shall be valid for the duration of my claim.
“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. In New York the person 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. In California, any person who knowingly files a statement of claim containing any
false or misleading information is subject to criminal and civil penalties.”
B
,
EFORE SIGNING THIS CLAIM FORM
PLEASE READ THE WARNING FOR THE STATE WHERE YOU RESIDE AND FOR THE STATE
.
WHERE THE INSURANCE POLICY UNDER WHICH YOU ARE CLAIMING A BENEFIT WAS ISSUED
Please Note: Your Social Security number is required for IRS tax reporting purposes. Your Social Security number will not be used
or disclosed to anyone for any other purpose and will not be retained in any record other than that pertaining to the claim.
_______________________________________________________________
__________________________
Signature of employee or Power of Attorney (attach Power of Attorney papers if applicable)
Date
_______________________________________________________________
__________________________
If a dependent claim, signature of adult dependent or Power of Attorney (attach Power of Attorney papers if applicable)
Date
GG016448
(10/14)
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