Hsr Boy Scouts Of America Insurance Claim Form

To be completed by BSA Leader

Council Name:

__________________________________

Address:

__________________________________

BOY SCOUTS OF AMERICA

HSR Plaza

1. PLEASE FULLY COMPLETE THIS FORM

__________________________________

4100 Medical Parkway

2. ATTACH ITEMIZED BILLS WITH DOCTOR’S

Telephone Number:

Carrollton, TX 75007-1517

DIAGNOSIS

__________________________________

Toll Free 866-726-8870

3. MAIL TO HEALTH SPECIAL RISK, INC.

Fax 972-512-5820

ACE American Insurance Company

E-Mail:

P AR T 1 - B S A C o u n c i l R e p r e s e n t a t i ve S t a t e m e n t

Check One:

Tiger Cub

Tiger Cub Adult

Cub

Scout

Venturer

Varsity Scout

Leader

Explorer

Learning for Life – Curriculum Based

Volunteer Seasonal Staff

Committee

Family Member

Check Policy:

Council

Unit

Campers & Special Events

National Events

Check One:

Are you a member of or is your unit sponsored by the Church of Latter Day Saints?

Yes

Any participant in an LDS sponsored

unit is ineligible for coverage under this policy because their church has already provided insurance through another company Deseret Mutual (1-800-777-3622).

Pack, Troop, Post, Team or Crew #

1. Claimant’s Name (Injured/Sick Person)

2. Social Security Number

3. Gender

4. Birthday

__M

__F

___ / ___ / ___

5. Claimant’s Address (Street, City, State, Zip Code) and best contact telephone number (include area code)

6. If applicable, parent’s name, address and best contact telephone number (include area code)

7. E-Mail

8. What date did accident happen or sickness begin?

9. Nature of injury or sickness (indicate part of body injured – such as broken arm, sprained ankle, etc.)

10. Describe how accident occurred – give details

Did Injury Result in Death?

YES

11. Name of event or activity

12. Name and title of adult leader

13. Signature of council representative

14. Title

15. Date

P AR T 2 – O t h e r I n s u r a n c e S t a t e m e n t

Do you/spouse/parent have medical/health care or is the Claimant enrolled as an individual, employee or dependent member of a Health Maintenance

Organization (HMO) or similar prepaid health care plan, or any other type of accident/health/sickness plan coverage through your employer or other source on you

or does your son/daughter have health care coverage as a dependent from your previous marriage as mandated in a divorce decree?

YES

If Yes, name of insurance company _________________________________________________________ Policy #________________________________

Name of second insurance company ___________________________

_________________________ Policy #________________________________

Coverage is Excess of All Other Insurance or Healthcare plans in Force

This policy is excess to any and all other available source of medical insurance or other healthcare benefits. You must file your bills through your

primary/personal insurance carrier or healthcare plan prior to this policy responding. When your primary insurance company or healthcare plan

processes the charges, they will send you an Explanation of Benefits, or “EOB.” Please submit copies of their Explanation of Benefits along with your

claim to Health Special Risk, Inc. In the event you have no other primary insurance or healthcare plan, this policy with pay as primary subject to the

plan limits and terms.

Please read & sign below: I agree that should it be determined at a later date there is insurance (or similar), to reimburse HEALTH SPECIAL

RISK, INC., or the insurance company to the extent of any amount collectible.

Signature of participant or parent

Date

N O T E : An y p e r s o n w h o k now i n g l y a n d w i t h i nt e n t t o d e f r a u d a n y i n s ur a n c e c om pa n y o r o t h e r p e r s o n f i l e s a n a pp l i c a t i o n f or i n s ur anc e or

s t a t e m e n t o f c l a i m c o n t a i n i n g a n y m a t e r i a l l y f a l s e i nf or m a t i o n o r c o n c e a l s f or t h e p u r p o s e o r m i s l e a d i n g, i nf or m a t i o n c o n c e r n i ng a n y f a c t

m a t e r i a l t h e r e t o c om m i t s a f r a u d ul e n t i ns ur a n c e a c t , w hi ch i s a c r i m e a nd s u b j e c t s s uc h p e r s o n t o c r i m i na l a n d c i v i l p e n a l t i e s .

A u t h o r i z a t i o n t o p a y b e n e f i t s t o p r o v i d e r

I authorize medical payments to physician or supplier for services described on any attached statements enclosed. (If not signed submit proof of payment)

Signature X_______________________________________________________ DATE _____________________

A u t h o r i z a t i o n f o r r e l e a s e o f i n f o r m a t i o n

I hereby authorize any insurance company, hospital, physician or other person who has attended or examined the claimant to disclose when requested to do so,

all information with respect to any injury, policy coverage, medical history, consultation, prescription or treatment, and copies of all hospital or medical records. A

photostatic copy of this authorization shall be considered as effective and valid as the original.

Signature X_______________________________________________________ DATE _____________________

ATTACH ITEMIZED BILLS WITH DOCTOR’S DIAGNOSIS

BSA 2012-8-8