Hsr Boy Scouts Of America Insurance Claim Form

HOW TO SUBMIT A CLAIM

Listed below are important instructions and comments about filing a claim.

YOUR CLAIM FORM

1. This claim form should be fully complete and submitted within 90 days from the date of injury. Be sure

to answer and complete the section regarding “OTHER INSURANCE STATEMENT”, marking either

yes or no and signing the line for authorization so that HSR and the doctors/hospitals may

communicate concerning your claim.

Incomplete claim forms are one of the most frequent reasons why claim payments are delayed.

2. The claim form must be signed by a policyholder representative (i.e. council, leader).

3. Only one claim form for each accident needs to be submitted.

4. Once completed, make a photocopy for your records and mail to the address shown below.

5. DO NOT assume that anyone else will mail this claim form to HSR for you.

YOUR BILLS

1. Please advise all doctors/hospitals regarding this coverage so they may forward their itemized bills to

us.

2. If you have already been to the doctor/hospital and did not know about this coverage, please send all of

the itemized bills you receive to HSR at the address shown below.

3. The bills should include the name of the doctor/hospital, their complete mailing address, telephone

number, the date you were seen by the doctor/hospital, what the doctor saw your for and the specific

itemized charges incurred.

4. If this information is not on the bill when you send it to us, we will have to contact the doctor/hospital

which will delay the review of your claim. “Balance Due” statements do not contain sufficient information

to complete your claim. Mailing HSR “Balance Due” statements will only delay the processing of your

claim.

EXCESS INSURANCE

The policy is excess to any other available source of medical benefits. This means that you must file

your bills through your primary, or personal, insurance carrier prior to this policy responding. When your

primary insurance company processes the charges, they will send you an Explanation of Benefits, or

“EOB”. You must forward a copy of the Explanation of Benefits for EACH CHARGE.

If you have any questions, please contact Customer Service from 8:00 AM thru 5:00 PM, Monday – Friday

at (866) 726-8870 or via e-mail at . You may also forward any documents by fax to

(972) 512-5820.

Health Special Risk, Inc.

4100 Medical Parkway

Carrollton, TX 75007

BSA 2012-8-8

Hsr Boy Scouts Of America Insurance Claim Form - 2012 Page 3