Form A112-2496 at a glance
What it is: A112-2496 Accident Claim Form V06.2022: an Accident Claim with Claim Information to be completed by the Policy Owner.
Who signs: Claim Submission Signature - To be completed by Policy Owner. Disclosure Authorization - To be completed by patient unless patient is a minor or legally incapacitated. Be sure to sign and date this section of the form, including DOB & last 4 digits of SSN where indicated.
Where and when to file: For Claims Customer Service: Phone: 877-201-9373 x45704. For Claims Submission: Fax: (508) 853-2867 Email: AccidentClaimsVB@Trustmarkbenefits.com
The Policy Owner is responsible for completion of all portions of this form without expense to Trustmark Companies.
Section A & B - To be completed by Policy Owner. Complete these sections in full and return for review of benefits.
What to bring and attach to Form A112-2496
Please be sure to include proof of treatment including medical records describing treatment date and diagnosis, itemized copies of any doctor, emergency room, hospital and motor vehicle incident/accident reports or records, complete hospital intake and discharge statement(s), UB-04 insurance billing form, HCFA or CMS 1500 billing form.
If surgery was done, please provide a copy of the operative report.
If claiming a fracture, please include an imaging report, such as an x-ray, showing the fracture.
For a laceration, please include the length of the operation and proof of stitches if received.
For Lodging/Transportation benefit(s), please include copies of Mapping, such as Google Maps, to document mileage to facility/treatment, and hotel bills for lodging.
If accident was the result of a MVA (motor vehicle accident), please provide complete copy of motor vehicle incident/accident police report.
A filled-in Form A112-2496 example: a policy owner claims for a child's fall
How to fill out Form A112-2496, box by box
Section A - Policy Owner Information
Section A - Policy Owner Information is to be completed by the Policy Owner: enter the Policy/Certificate# and the SSN Number (last 4 digits).
Enter the Name and DOB, then the Address (Street Apt #) and the City State Zip Code.
Enter the Phone # and mark Home, Cell or Work; enter the E-Mail Address.
Note: To authorize texting please complete the E-Sign Disclosure and Consent Notice.
Section B - Claim Information
Section B - Claim Information is to be completed by the Policy Owner. Please complete and attach supporting documentation outlined on the Instructions for Claim Submission page, as well as items as indicated throughout the form.
Enter the Name of patient, DOB and SSN.
Mark Policyholder, Spouse, Child or Other for the Relationship to Policyholder.
Enter the Date of accident and the Diagnosis.
Please provide description of accident including where the accident occurred and what happened to the patient.
Motor Vehicle Accident (MVA) and on the job
Is accident a result of a Motor Vehicle Accident (MVA)? Mark Yes or No. If Yes, a copy of MVA report is needed.
Did the accident occur while on the job? Mark Yes or No. If Yes, a copy of work incident report is needed.
Date of Initial Treatment and Where Treatment Received
Enter the Date of Initial Treatment and the Date of Follow-Up Visit. Mark Where Treatment Received and Where Follow-Up Treatment Received: Urgent Care, Emergency Room (ER), Doctor's Office or Other.
Disclosure Authorization
DISCLOSURE AUTHORIZATION: enter the Insured's name (Patient) (Please Print) and the Last 4 of SSN#.
Patient Signature (or Policy Owner, if Patient is under 18): mark Signed by Policy Owner or Patient and enter the Date Signed, the Patient's Date of Birth and the Relationship, if other than insured.
This Authorization will be in force for the duration of the claim or up to 12 months from the date shown, whichever time period is less.
If you revoke or fail to sign this authorization or alter its content it may affect the handling of your claim, including denial of benefits under your policy.
Claim Submission Signature
Claim Submission Signature: The statements made on this claim are true and complete. The fraud notices contained in this form have been read and understood.
Enter the Signature of Policy Owner, Print Name and Date signed.
If you receive benefit payments greater than those which should have been paid, you will be requested to provide a lump sum repayment to the insurance company. The insurance company has the option to reduce or eliminate future benefit payments, to the extent allowed by law, in order to recover any overpayment balance that is not returned.
More rules for Form A112-2496
This is not a guarantee of payment. Benefits will be determined based on your policy provisions.
For the coverage under which benefits claimed: If premium is more than 30-days behind your claimed date of loss, past due premiums will be deducted from any benefits paid.
Other situations
Hospital confinement
Please provide information pertaining to first date of hospital confinement. Room & Board Charge must be incurred.
Confinement in a rehab facility is not a covered benefit.
ICU = Intensive Care Unit. Observation Unit requires admission of at least 20 hrs.
Mark the Type of Room: Regular, ICU or Observation Unit; enter the Admission Time and Discharge Time. Please list all additional dates of confinement.
Physical Therapy
Please complete if you are claiming physical therapy. Physical Therapy must be performed by a licensed physical therapist. There is a maximum of 6 Physical Therapy visits per Covered Accident.
Enter the Date of initial physical therapy visit, then the Date(s) of Physical Therapy, Name of Facility and Address of Facility.
Fracture or Dislocation
Please complete if you are claiming a fracture or dislocation. Proof of diagnosis is required. If surgery was done the operative report is required.
List the Bone(s).
Was surgery required? Mark Yes or No and enter the Date of Surgery. Was anesthesia required? Mark Yes or No.
Surgery
Surgery: When a Covered Person undergoes Surgery as a result of a Covered Accident benefits may be payable depending on the surgery type. Please complete if you are claiming a surgery benefit. Copy of operative report is required.
Enter the Date of Surgery, the Description of Surgery, the Name of Facility where surgery was completed and the Address of Facility.
Other Benefits
Other Benefits: Please complete for other benefits you are claiming. Mark Yes or No for each benefit.
Air Ambulance Benefit: Yes or No. Please provide proof of transport.
Ground Ambulance Benefit: Yes or No. Please provide proof of transport.
Appliance Benefit: Yes or No. Please provide prescription for appliance (e.g. crutches, wheelchair, etc.).
Concussion Benefit: Yes or No. Please provide proof of diagnosis.
Laceration: Yes or No. Please provide proof of length and repair (i.e. stitches), if applicable.
Eye Injury: Yes or No. Please provide proof of surgery or the removal of foreign object.
Burn Benefit: Yes or No. Please provide proof showing degree and % of body surface.
Skin Graft: Yes or No. Please provide operative report.
Blood/Plasma/Platelet: Yes or No. Please provide medical record.
Emergency Dental: Yes or No. Please provide dental record showing treatment due to an accident.
Transportation: Yes or No. Please provide proof of appointment and mileage.
Lodging: Yes or No. Please provide proof of lodging and mileage.
Loss of Finger/Toe/Foot/Sight: Yes or No. Please provide operative report or medical record.
Prosthetic Device or Artificial Limb Benefit: Yes or No. Please provide proof of prescription and receipt.
Accidental Death Benefit: Yes or No. Please provide death certificate, police report and autopsy.
Accident Death-Common Carrier: Yes or No. Please provide death certificate, police report and autopsy.
Catastrophic Accident Benefit: Yes or No. Please provide medical records showing total and irreversible loss of use.
PREFERRED METHOD OF COMMUNICATION
Optional: These sections of the claim form are not required but completing them will provide better and faster communication with you or anyone you designate.
PREFERRED METHOD OF COMMUNICATION: Text Messages and Email - Please provide cell phone #, or Only Email - Please confirm email address.
Before you go
Incomplete or illegible answers may result in delay of benefits.
Common questions about Form A112-2496
Where do I file it?
For Claims Customer Service: Phone: 877-201-9373 x45704. For Claims Submission: Fax: (508) 853-2867 Email: AccidentClaimsVB@Trustmarkbenefits.com
Where to get help with Form A112-2496
Please keep a copy of all parts of this form and any supporting documentation for your records.
Sources
[1] Form A112-2496 Accident Claim Form V06.2022 (2-20), Trustmark Insurance Company (the Official source link on this page).
