Accident And Sickness Claim Form/ Global printable pdf download

PROOF OF LOSS

Maksin Management Corp.

NAME OF GROUP:

ASSE International, Inc.

ASPIRE Worldwide Programs

P.O. Box 2038

Camden, NJ 08101

POLICY NUMBER:

9109341

866-723-6674

ACCIDENT AND SICKNESS CLAIM FORM/ GLOBAL

INSTRUCTIONS:

1.)

This form is to be used when filing a claim for reimbursement of Medical and Dental Expenses.

2.)

Section A must be completed by the Insured in full.

3.)

One of the following must be provided:

•

Section B Fully Completed by the Attending Physician, or

•

Fully Itemized Bills showing Claimant’s Name, Nature of Illness/Injury, Description and Charge for each service provided.

4.)

This form must be signed and dated in all applicable sections.

5.)

This form and all attached bills must be submitted to the address indicated above.

The furnishing of this form, or its acceptance by the Company, must not be construed as an admission of any liability on the Company, nor a waiver of any of the

conditions of the insurance contract.

SECTION A

(PLEASE PRINT)

Coverage Effective Date

_____/_____/______

Coverage Termination Date: _____/_____/____

1.) Name of Claimant:

Claimant's Date of Birth: ______/______/______

Sex:

Male

Female

2.) Current Residence Address:

3.) Date of arrival in U.S.: ______/______/______

Daytime phone number:

(

)

4.) Permanent Address (In Home Country):

5.) If injury, give date injury occurred and details of the injury/accident:

6.) If Illness, advise when and where symptoms first occurred:

Country ____________________

Date ____________________

Please indicate nature of the illness and/or describe your symptoms:

7.) Have you been treated for this illness or injury prior to the effective date of this insurance?

If yes, provide name and address of the treating Physician(s) and date(s) first consulted.

8.) Provide Name and Address of your Regular Physician in your Home Country:

9.) Were you taking any medications prior to the effective date of this insurance?

__________ If yes, please provide the following:

Drug Name:

_______________________ Drug Name:

_______________________

Prescribed for:

_______________________ Prescribed for:

_______________________

Physician Name:

_______________________ Physician Name:

_______________________

Date 1

Prescribed: _______________________ Date 1

Prescribed: _______________________

10.) Do you have other health insurance?

Yes _____

No _____

If yes, please provide the name, address and policy number of the Insurance:

I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

AUTHORIZATION and ASSIGNMENT OF BENEFITS

I, the undersigned authorize any hospital or other medical-care institution, physician or other medical professional, pharmacy, insurance support organization, governmental agency,

group policyholder, insurance company, association, employer or benefit plan administrator to furnish to the Insurance Company named above or its representatives, any and all

information with respect to any injury or sickness suffered by, the medical history of, or any consultation, prescription or treatment provided to, the person whose death, injury,

sickness or loss is the basis of claim and copies of all of that person's hospital or medical records, including information relating to mental illness and use of drugs and alcohol, to

determine eligibility for benefit payments under the Policy Number identified above. I authorize the group policyholder, employer or benefit plan administrator to provide the

Insurance Company named above with financial and employment-related information. I understand that this authorization is valid for the term of coverage of the Policy identified

above and that a copy of this authorization shall be considered as valid as the original. I understand that I or my authorized representative may request a copy of this authorization.

I authorize payment of medical benefits to the physician or supplier for service performed.

YES

Optional Limited Assignment

hereby make a limited assignment to

(my "Assignee") of the right to receive the benefits due for those covered medical

expenses incurred by me and actually paid directly to the provider of those services by my Assignee. I understand that the Company bears no responsibility or liability for the

validity or effect of this assignment or for any payments made by the Company prior to receipt of satisfactory proof of payment by the Assignee. I hereby specifically release, and

agree to indemnify, the Company from any and all liability incurred for any such payments made.

CALIFORNIA: For your protection, California law requires the following to appear on this form: 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.

For residents of New York: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance 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 subject motor vehicle or stated claim for each such violation.

For residents of Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files a 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 subjects such person to criminal and civil penalties.

For claimants not residing in California, New York, or Pennsylvania: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or

knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

CLAIMANT OR AUTHORIZED PERSON’S SIGNATURE:

DATE:

GLOBAL/rev 1.0, 8/2002