The attached claim form is to be provided to the parents and/or the claimant by the insurance coordinator.

• The insurance coordinator must complete the bottom portion of the claim form.
  
  
• The remainder of the form (Proof of Loss) is to be completed, and signed, by the parent/guardian/claimant.

If you have any questions regarding the filing of a claim, please contact our Claims Department at 1 -800-237-2917.

INSTRUCTIONS FOR INSURANCE COORDINATOR

• You must indicate the name of the team, league and/or association on the claim form. This information is found on the Certificate of Insurance in the upper left-hand corner.
  
  
• Please complete the bottom portion of the claim form in its entirety.

INSTRUCTIONS FOR PARENTS

• Please be advised that this coverage is subject to a $100 deductible and is excess/secondary to any other valid and collectible coverage available to the claimant. This means that if there is other health and/or accident coverage available, all charges must be submitted to them first on a primary basis. Subject to the terms and conditions of this policy, coverage will apply to the amount not covered by other insurance. If you have other coverage, the other carrier’s payment(s) will be used to satisfy the deductible under this policy. If you have no other coverage, we will apply the $100 deductible to the charges received until the deductible has been satisfied.
  
  
• You are responsible for completing the upper portion of the claim form. Omission of any information may cause a delay in the processing of your claim.
  
  
• Only expenses incurred within 104 weeks from the date of accident will be considered.
  
  
• If you have coverage under an HMO plan, but do not seek treatment from a provider within that plan, your benefits under this policy may be reduced by the amount that would have been paid had the services been provided by a provider within your HMO plan. You would also be responsible for the deductible under this plan.
  
  
• Attach all itemized charges along with the explanation of benefits from any other insurance showing what has, or has not, been paid. We will then process the outstanding portion of your claim in accordance with the terms and conditions of this policy.
  
  
• Verify that the insurance coordinator has completed the lower portion of the claim form in its entirety.