Underwritten by Life Insurance Company of North America, a CIGNA Company
INTERCOLLEGIATE ATHLETIC ACCIDENT INSURANCE CLAIM FORM
Walla Walla University • 204 South College Ave. College Place, WA 99324-1198 FRAUD WARNING: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. CLAIM FILING INSTRUCTIONS: 1. Part 1 - Must be completed by appropriate university official. 2. Part 2 - Must be completed by claimant or by the parent or guardian, if the claimant is a minor. 3. Send copies of itemized bills showing provider’s name, address, tax ID number, diagnosis and procedure codes. 4. Attach Explanation of Benefits, additional bills with record of payment or denial from primary insurance carrier. 5. All benefits will be payable to the physicians and providers, unless accompanied by paid receipts.
Claim Calls to: (800) 634-8628 Fax to Campus Health & Wellness: (509) 527-2426
PART I - POLICYHOLDER’S REPORT
1. Name of Insured Person 4. Address of Insured Person Street 5. Date of accident City 6. Time of accident State 7. Place where accident occurred Zip Phone 2. Sex __F __M 3. Birth Date _____/_____/______
8. Identify Sport Insured Person was participating in:
9. Did accident occur during practice or during a game? __Practice__Game
10. Nature of injury (Indicate part of body injured - such as broken arm, sprained ankle, etc.) 11. Describe how accident occurred - Give all possible details. Attach separate sheet if necessary. Must be a bodily injury due to accident. 12. Did accident occur (circle YES or NO for each of the following): A. During a policyholder sponsored & supervised activity: B. While traveling directly or uninterruptedly to and from home and policyholder premises? 13. Name of event or activity 15. SIGNATURE OF SCHOOL REPRESENTATIVE 14. Name & Title of Supervising Representative 16. POLICY NUMBER 17. DATE
YES YES
NO NO
PART II - OTHER INSURANCE STATEMENT
1. Do you/spouse/parent have medical/health care coverage through your employer or other source for you? YES_____ NO_____ If yes, who is the subscriber? Self_____ Parent_____ Spouse_____ Other_____ 2. Please provide if different than claimant: Subscriber name_________________________________ Street_____________________________________________________________________ City____________________________________________ State__________ Zip_______________ Phone_____________________________ 3. Type of insurance? PPO_____ HMO_____ Major Medical_____ Other_____ 4. Insurance Company: Name______________________________________ ID #______________________ Group #____________________ Street________________________________ City_____________________________ State______ Zip_________ Phone_____________ If your son/daughter has health care coverage as a dependent from your previous marriage as mandated in a divorce decree, please provide the following: Name of Insurance Company_________________________________________________________ Policy #___________________________ 5. Are you covered under your school’s Student Health Plan? YES_____ NO_____
AUTHORIZATION TO RELEASE INFORMATION
AFFIDAVIT: I verify that the statement on other insurance is accurate and complete. I understand that the intentional furnishing of incorrect information via the U.S. Mail may be fraudulent and violate federal laws as well as state laws. I agree that if it is determined at a later date that there are other insurance benefits collectible on this claim I will reimburse the Company to the extent for which the Company would not have been liable. AUTHORIZATION TO RELEASE INFORMATION: I authorize any Health Care Provider, Doctor, Medical Professional, Medical Facility, Insurance Company, Person or Organization to release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information concerning the patient, to any CIGNA company, its employees, and authorized agents for the purpose of validation and determining benefits payable. I further authorize any CIGNA company to furnish the Policyholder or its agents, any and all information with respect to my insurance claim for the purpose of assisting with claims adjudication. This data may be extracted for audit or statistical purposes. I understand that I have the right to revoke this authorization in writing at any time and that such a revocation is not effective to the extent it has already been relied upon. PAYMENT AUTHORIZATION: I authorize all current and future medical benefits, for services rendered and billed as a result of this claim, to be made payable to the physicians and providers indicated on the invoices. Signature (Parent or guardian if claimant is a minor) Date Phone Number