Contents
Form Example
STUDENT ACCIDENT CLAIM FORM
SUBMIT CLAIM FORM TO: Fidelity Security Life Insurance Company c/o Universal Fidelity Life Insurance Company P.O. Box 304
Duncan, OK
Section 1 - Notice of Injury |
(To be completed by School Official) |
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(This section may be completed by parent if |
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Name of School District: |
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Name of School: |
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School Phone No: |
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Name of Injured Student: |
□ Male |
□ Female |
Grade: |
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Date of Injury: |
Time of Injury: |
□ AM |
□ PM |
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Part of Body Injured: |
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□ Right Side |
□ Left Side |
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Under whose supervision?
Was accident witnessed? |
□ Yes |
□ No |
If "Yes", by whom? |
The accident happened while the student was participating in: |
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□ Interscholastic UIL Activity |
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□ Non Interscholastic UIL Activity |
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Specify Sport/Activity:
Explain in detail how and where the injury occurred: ___________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Signature of School Official: ________________________________________________________________________________________________
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(Title) |
(Date) |
IMPORTANT INFORMATION ON REVERSE SIDE |
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Section 2 - Parent/Guardian Statement (To be completed by Parent/Guardian) |
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Name of Student: |
Date of Birth: |
Home Phone No: |
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Is student covered by any insurance plan? □ Yes □ No |
If yes, |
Policy No. |
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Parent/Guardian Name: |
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Relationship to Student: |
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Address: _________________________________________________________________________________________________________________
(Street) |
(City) |
(State) |
(Zip) |
Father's Name: |
Father's Employer: |
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Name of Father's Insurance Company (must be completed - If Father has no insurance - write "None"):
Insurance Company: |
Policy No. |
Mother's Name: |
Mother's Employer: |
Name of Mother's Insurance Company (must be completed - If Mother has no insurance - write "None"):
Name of Insurance Company: |
Policy No. |
I hereby authorize any insurance company, their authorized agent, hospital, physician, employer, school official 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, consultations, prescription or treatment, and copies of all hospital or medical records, and itemized bills. A photo static copy of this authorization shall be considered as effective and valid as the original. I swear that the above information is true and correct to the best of my knowledge. I further understand that any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
__________________ |
_____________________________________________ |
______________________________________________________ |
(Date) |
(Print Name of Student) |
(Signature of Parent/Guardian) |
Form |
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ATTENTION PARENTS
Dear Parents,
Below are instructions for filing the Claim Form. Should you have any questions, contact the school trainer or call the number listed below. The school is NOT responsible for medical payment for your child. The school may have purchased a supplemental Accident Only Policy which may cover charges in excess of your own insurance policy. If you have no other insurance for your child, this policy may pay first or primary. This is a limited benefit policy and may not cover all medical bills for your child. Any charges not covered are YOUR RESPONSIBILITY.
For all
INSTRUCTIONS FOR FILING THE CLAIM FORM
Section 1 must be completed by a school official for all
Section 2 must be completed by the parent / guardian.
How to File A Claim
Step 1 - Complete and submit the claim form to the Claims Office at the address indicated below or send electronically to SAclaims@uflic.com. The claim form must be submitted within 90 days from the date of injury regardless of whether you have other insurance or not. Keep a copy of the claim form for your records and present a copy of the claim form to the provider or facility. DO NOT RELY on the provider or facility to submit the claim form.
Submit copies of itemized bills to the address indicated below. Itemized bills are original bills you receive, not monthly statements. Itemized bills are often called UB92 or HCFA1500 forms that provide the procedure code, diagnosis code, and the Providers’ address and Tax ID Number.
Step 2 - File a claim with your primary insurance first. insurance is your family and/or group insurance coverage.
Submit copies of all bills to your primary insurance first. Your primary The school’s policy is supplemental to all other valid coverage.
Step 3. After receiving payment or copies of Explanation of Benefits (EOB) from your family and/or group insurance, submit a copy of this claim form along with copies of your itemized bills and EOBs from your primary insurance company to the address below:
Fidelity Security Life Insurance Company c/o Universal Fidelity Life Insurance Company
P.O. Box 304
Duncan, OK
(800)
Texas Kids First has unique access to one of the most creative innovations in the insurance industry – the Texas Kids First Provider Network (TKF Network)* – the first “no balance bill”
Please refer to the website www.texaskidsfirst.com or call
*The TKF Network is made available by Texas Kids First and is not affiliated with Fidelity Security Life Insurance Company.
FRAUDULENT CLAIM DISCLOSURE
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
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Common mistakes
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Incomplete Information: Failing to fill out all required fields can lead to delays or denials. Ensure every section is completed accurately.
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Missing Signatures: Forgetting to sign the form can result in processing issues. Both the school official and the parent/guardian must provide their signatures.
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Incorrect Dates: Entering the wrong date of injury or date of submission can complicate the claim process. Double-check these details before submitting.
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Not Providing Itemized Bills: Submitting generic statements instead of itemized bills can lead to claim rejections. Always include detailed billing information.
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Neglecting to Notify Primary Insurance: Failing to file a claim with your primary insurance first can delay reimbursement. Always follow the steps in the instructions.
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Incorrect Policy Information: Providing inaccurate insurance policy numbers or details can hinder the claims process. Verify all information before submission.
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Ignoring Deadlines: Submitting the claim form after the 90-day deadline can result in denial. Keep track of important dates to ensure timely submission.
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Not Keeping Copies: Failing to retain copies of the submitted claim form and bills can be problematic. Always keep a record for your own reference.
Key takeaways
Filling out the Texas Clm 2 form correctly is essential for ensuring that claims are processed smoothly. Here are some key takeaways to keep in mind:
- Section 1 must be completed by a school official for school-related accidents.
- If 24-Hour coverage was purchased and the accident is not school-related, parents can fill out Section 1.
- Make sure to include detailed information about the injury, including the time and date of the incident.
- Section 2 is specifically for the parent/guardian to complete.
- List any insurance coverage that the student has; this information is crucial.
- Submit the claim form within 90 days of the injury to ensure timely processing.
- Keep a copy of the claim form for your records; do not rely on providers to submit it for you.
- Itemized bills are necessary; these should be original bills and not monthly statements.
- File a claim with your primary insurance before submitting to Fidelity Security Life Insurance Company.
- Utilize the Texas Kids First Provider Network for potential benefits if your child has no other insurance.
Understanding these points can simplify the claims process and help secure the necessary coverage for medical expenses. Always refer to the instructions on the form for specific details and requirements.
Steps to Using Texas Clm 2
Filling out the Texas Clm 2 form is an essential step in addressing student accidents. Once completed, the form needs to be submitted to the appropriate claims office for processing. It is crucial to follow the instructions carefully to ensure that all necessary information is provided and that the claim is filed within the required time frame.
- Begin with Section 1, which should be filled out by a school official. If 24-Hour coverage was purchased and the accident is not school-related, a parent or guardian can complete this section.
- Provide the name of the school district, the name of the school, and the school phone number.
- Enter the name of the injured student, their gender, and grade level.
- Record the date and time of the injury, specifying whether it occurred in the AM or PM.
- Indicate the part of the body that was injured, selecting either the right or left side.
- Note under whose supervision the injury occurred and whether the accident was witnessed. If it was witnessed, include the name of the witness.
- Specify the activity during which the injury happened, choosing between Interscholastic UIL Activity or Non Interscholastic UIL Activity. If applicable, specify the sport or activity.
- Provide a detailed explanation of how and where the injury occurred in the space provided.
- Have the school official sign and date the form.
- Proceed to Section 2, which must be completed by the parent or guardian. Fill in the name and date of birth of the student, along with a home phone number.
- Indicate whether the student is covered by any insurance plan. If yes, include the policy number.
- Complete the parent or guardian’s name, relationship to the student, and address.
- Provide the names and employers of both the father and mother, along with their respective insurance companies and policy numbers. If either parent does not have insurance, write "None."
- Sign and date the authorization statement, confirming that the information provided is accurate and acknowledging the consequences of presenting a fraudulent claim.
- Make a copy of the completed claim form for your records before submission.
- Submit the claim form to Fidelity Security Life Insurance Company at the provided address or electronically to SAclaims@uflic.com within 90 days of the injury.
- Send copies of itemized bills to the same address. Ensure these bills are original documents, not monthly statements.