Universities: Accident Details

HEALTH INSURANCE RESPONSE FORM – ACCIDENT DETAILS

HealthSmart Benefit Solutions partners with your school's plan to process member claims. (“Claims” are formal requests for the plan to pay for services you’ve utilized, usually submitted by the providers you see.)

We have received an accident claim and need additional information from you in order to complete our processing of your claim.

1. What school do you attend? *

2. Last name: *

First name: *

3. Your insurance ID number (located on your insurance ID card): *

Group number: *

4. Date of accident: * 🛈 +

Time of the accident: *

5. Location where the accident occurred: *

6. Please describe the details of the accident or injury that occurred: *

7. Did this injury happen while participating in one of the following? (Select one) *

8. Was the injury the result of a motor vehicle accident? *

Yes

9. If "Yes," please provide the name of the other driver in the accident:

10. Other driver’s address and phone number:

11. Other driver’s insurance company name and phone number:

12. Please provide the details of what occurred in your motor vehicle accident: