Accident Details

HEALTH INSURANCE RESPONSE FORM – ACCIDENT DETAILS

Thank you for selecting The Ohio State Student Health Insurance Benefits Plan. HealthSmart Benefit Solutions partners with the 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. Last name: *

First name *

2. Your SR ID# (the 7 digit number on your Health Insurance ID card) *

Group number *

3. Time of the accident: *

Date of accident: * 🛈 +

4. Location where the accident occurred: *

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

6. Did this injury happen while participating in one of the following? (select one): *

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

Yes

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

9. Other driver's address and phone number:

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

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