7400 College Blvd, Suite 100
Overland Park, KS 66210
800-955-1991   Fax: 913-327-7520

 
Fields marked with * are required
Claimant Information
Organization/School Name:*  
Claimant's Name:*  
Claimant's ID Number:*  
Claimant's Gender:*  
Claimant's Date of Birth:*  
Address:*  
City:*   State:*   Zip:*  
Home phone:*  
 
Accident Details
Date & Time Accident or Illness Began:*  
Was accident due to employment?:
Have you been treated for this condition before?*  
Type of Injury:*  
Description of Accident:*  
 
 
Parent/Guardian Information
Parent/Guardian Name:*  
Address:*  
City:*   State:*   Zip:*  
Employer Name:*   Employer Phone:
 
Name of all companies providing your insurance coverage of prepaid health plans.
Do you have any other insurance, including but not limited to group or individual health and/or accident, government plan, or automotive plan?*  
Ins. Company Name:  
Address:  
City:   State:   Zip:  
Policy Number:  
Are benefits due for this claim under other insurance coverages?
 
 
Authorization to Release Information

I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information, to Summit America Insurance Services, L.C., the Plan Administrator, or their employees and authorized agents for the purpose of validating and determining benefits payable. A photo copy of this authorization shall be as valid as the original.

  Dated: 4/24/2014
 
Authorization to Pay Provider

I authorize payment of charges associated with this incident directly to the physicians or providers. I further certify that the foregoing information is true and correct.

  Dated: 4/24/2014
 
Acknowlegement/Electronic Signature

I hereby certify that all of the above information is true and complete and I have read and understand the fraud statement below.

  Dated: 4/24/2014



 

IMPORTANT NOTICE
This plan of insurance is secondary to any health insurance you have. Submit your claim to your primary health insurance company first. When you receive an Explanation of Benefits Statement, send it along to us with our itemized bill and this completed form.
Payment will be made to the providers of service (Hospital, Physician or Others), unless a paid receipt statement accompanies the bill at the time the claim is submitted.

Fraud Statements

The following fraud language is made part of and cannot be removed fro this claim form. Please read carefully.

  • Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company fi les a claim containing false, incomplete, or misleading information may be prosecuted under state law.
  • Arizona: 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.
  • Arkansas or Louisiana: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefi t or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fi nes and confi nement in prison.
  • California: For your protection California law requires the following to appear on this form. 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 fi nes and confi nement in state prison.
  • Colorado: 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, fi nes, 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 purpose 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 regulatory agencies.
  • Delaware: Any person who knowingly, and with intent to injure, defraud, or deceive any insurer, fi les a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
  • District of Columbia: 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 benefi ts if false information materially related to a claim was provided by the applicant.
  • Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer fi les a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
  • Idaho: Any person who knowingly, and with intent to defraud or deceive any insurance company, fi les a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
  • Indiana: A person who knowingly and with intent to defraud an insurer, fi les a statement of claim containing any false, incomplete, or misleading information, commits a felony.
  • Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person fi les 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.
  • Maine, Tennessee or Virginia: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fi nes and a denial of insurance benefits.
  • Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
  • New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, fi les a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
  • New Jersey: Any person who knowingly fi les a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
  • New Mexico: 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 CIVIL FINES AND CRIMINAL PENALTIES
  • New York: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN 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 SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION. (PURSUANT TO 11 NYC RR86)
  • Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or fi les a claim containing a false or deceptive statement is guilty of insurance fraud.
  • Oklahoma: 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.
  • Pennsylvania: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
  • Puerto Rico: Any person who knowingly, and with intent to defraud or deceive any insurance company includes false information in an application for insurance or fi les, assists, or abets in the fi ling of a fraudulent claim to obtain payment of a loss or other benefi ts, or fi les more than one claim for the same loss or damage, may be guilty of a felony. Upon conviction, that person will be fi ned between $5,000 and $10,000, imprisoned for three (3) years or both. Aggravating or attenuating circumstances may result in the prison term being increased to fi ve (5) years or reduced to two (2) years.
  • Texas: 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.
  • If you live in a state other than mentioned above, the following statement applies to you: Any person who knowingly, and with intent to injure, defraud or deceive any insurer or insurance company, fi les a statement of claim containing any materially false, incomplete, or misleading information or conceals any fact material thereto, may be guilty of a fraudulent act, may be prosecuted under state law and may be subject to civil and criminal penalties. In addition, any insurer or insurance company may deny benefi ts if false information materially related to a claim is provided by the claimant.