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