Trustmark Accident Claim Form – Fill Out and Use

TRUSTMARK INSURANCE COMPANY

ACCIDENT CLAIM FORM

PO BOX 7937 • LAKE FOREST IL 60045-7937 1-800-918-8877 • FAX 1-847-615-3128 www.trustmarkins.com/customersolutions

This form must be completed by the attending physician and the policy owner and be returned to us for consideration of benefits. If you are claiming under the Accident Disability Benefit, the Employer section must be completed. All questions on this form must be answered in full. Incomplete or illegible answers may result in delay of benefit consideration. Please keep a copy of this form and any attachments for your records.

The policy owner is responsible for completion of all portions of this form without expense to Trustmark Insurance Company.

FRAUD NOTICE: Any person who knowingly and with intent to defraud an insurer files an application or a statement of claim containing any false, incomplete or misleading information may be guilty of insurance fraud which is a crime.

INSTRUCTIONS:

Section A & B: These sections must be completed by you, the policy owner.

Section C: This section must be completed by the physician who is treating you for this disability/accident.

Section D: This section must be completed by your employer if you are filing a claim for the Accident Disability Benefit.

State Required Fraud Language: Attached for your information.

Disclosure Authorization: Your must sign and date this form. Provide a copy of the signed and dated form to your attending physician.

Please enclose any additional information that you feel will assist Trustmark in evaluating this claim.

SECTION A:

Policy/Certificate #:

Policy Owner Name:

Patient’s Name:

DOB:

Relationship to Policy Owner: Spouse Child

Self Other

Policy Owner Address:

Street

City

State

ZIP Code

Policy Owner Home Phone:

Policy Owner Work Phone:

Policy Owner Date of Birth:

Policy Owner Social Security #:

SECTION B: POLICY OWNER’S STATEMENT

Please complete below and attach itemized copies of any related bills, including doctor, emergency room, hospital and motor vehicle incident/accident report. Bills should include diagnosis information from your medical provider. B

Date of accident:Date of first treatment for the accident:

Please provide a description of where the accident occurred and what happened to you.

Primary Care Physician:					Phone No. of Primary Care Physician:
Street					City		State	Zip Code
Were you confined to a hospital?			Yes No If yes, please provide the following:
Name of Hospital:					Phone No. of Hospital:
HOSPITAL INFORMATION (If ever hospitalized or treated in a hospital for this condition)
Street					City		State	Zip Code
Dates of Hospitalization:

P383-28 (R10-08)

The statements made by me on this claim are true and complete. I have read and understand the fraud notices contained in this claim form.

Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

Signature of ClaimantPlease Print Name

I signed on behalf of the claimant, as _____________ (relationship). If Power of Attorney, Guardian or Conservator, please attach a copy

of the document granting authority.

Date Signed

SECTION C: ATTENDING PHYSICIAN STATEMENT

ICD -9 Code:			Diagnosis:
Was this condition the result of an accident? Yes No		If yes, was the accident work related? Yes No

Was the patient hospital confined? Yes No If yes, dates of confinement:

During confinement was the patient in intensive care or coronary care unit? Yes No If so, dates of confinement:

Hospital Name:			Hospital Address:
If the condition was a fracture, was it an avulsion/chip fracture? Yes				No
If the condition was a fracture or dislocation, was it an: Open Injury				Closed Injury
If the condition involved laceration(s), what is the length of each laceration?
If the condition was a burn, please indicate:		Second Degree: _____Percentage of Body Surface
		Third Degree: _____Square Inches of Body Surface

Did burn require skin grafting? Yes No

As a result of this accident, did patient sustain a concussion? Yes No

If yes, date diagnosis made and the medical imaging procedure used

Did the patient suffer from any broken teeth requiring crowns or extractions? Yes No

Did the patient undergo any surgery? Yes No If so, please provide a copy of the operative report.

Do you consider the patient to be completely unable to work from the date of the accident? Yes No

If yes, how long do you believe the patient should remain out of work?

Activities of daily living mean: basic human functional abilities for the patient to remain independent. These include: bathing, continence,

dressing, eating, toileting or transferring.

Is the patient considered to be house confined or unable to perform two or more activities of daily living? Yes No

If yes, dates: From

To

(This information will be used in accordance with state regulations and policy provisions.)

Was this patient referred to you from another physician? Yes

No If yes, please provide the following:

Name of Referring Physician:

Telephone Number:

Street

City

State

Zip Code

Physicians name (please print)

Degree

Specialty

Telephone No.

Street

City

State

Zip Code

Signature of the Doctor

Date

Fax No.

State Required Fraud Warnings

New Hampshire Residents: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud.

Arizona Residents - For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

CaliforniaResidents-ForyourprotectionCalifornialawrequiresthefollowingtoappearonthisform.Anypersonwhoknowingly presents falseorfraudulentclaimforthepaymentofalossisguiltyofacrimeandmaybesubjecttofinesandconfinementinstateprison.

ColoradoResidents-It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages.Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purposes of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of RegulatoryAgencies.

Kansas and Oregon Residents: Any person who knowingly, and with the intent to injure, defraud, or deceive an insurance company, files a statement of claim containing any false, incomplete, or misleading information may be guilty of insurance fraud, which may be a crime.

KentuckyResidents -Aperson 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.

Arkansas, Louisiana and West Virginia Residents: 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.

MinnesotaResidents-Aperson who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

FRAUD WARNING FOR WASHINGTON, MAINE, TENNESSEE AND VIRGINIA RESIDENTS: IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY. PENALTIES MAY INCLUDE IMPRISONMENT, FINES AND DENIAL OF INSURANCE BENEFITS.

FRAUD WARNING FOR PENNSYLVANIA RESIDENTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES ANY 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 SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.

NewJerseyResidents-Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

Fraud Warning for Oklahoma, as well as for the residents of all states not specifically listed WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

FraudWarningforAlaskaResidents-Aperson who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

FraudWarningforDistrictofColumbiaResidents-WARNING:It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

FraudWarningforNewMexicoResidents-ANYPERSON WHO KNOWINGLYPRESENTSAFALSE OR FRAUDULENTCLAIM FOR PAYMENTOFALOSS OR BENEFITOR KNOWINGLYPRESENTS FALSE INFORMATION INANAPPLICATION FOR INSURANCE IS GUILTYOFACRIMEAND MAYBE SUBJECTTO CIVILFINESAND CRIMINALPENALTIES.

FraudWarningforOhioResidents-Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

FraudWarningforTexasResidents-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.

Fraud Warning for Maryland Residents - Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

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