Insure and Go USA Claim Form

InsureandGo USA – Emergency Medical / Dental Expense Claims Form
Insure and Go USA
Claim Form
Date:
7300 Corporate Center Drive Suite 601
Miami, FL 33126
Claim No.:
Emergency Medical / Dental Expense
Name of Insured
Home Address
State
City
Zip
Home Telephone
Date Of Birth
Cell Phone
E-mail Address
Mailing Address, if different from Home Address:
Street Address
State
City
Zip
Plan Information/ Trip Information
Policy #
Date Incident Occurred
Departure Date
Return Date
Original Destination
Travel Agency Name
Date of Initial
Deposit/Payment
Travel Agency Phone #
Traveling Companions (Please indicate name and relationship to you)
1.
6.
2.
7.
3.
8.
4.
9.
5.
10.
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InsureandGo USA – Emergency Medical / Dental Expense Claims Form
Health Carrier Coverage Information
In order for us to properly coordinate your Emergency/Medical/Dental benefits with your Health/Dental Insurance, please
indicate the name and policy number of your health carrier below.
Health
Street
Insurance
Address
Carrier
State
City
Policy #
Zip
Policyholder Name
If Medicare is your health insurance carrier, please list your HICN#:
(this number can be found on your Medicare card)
If you do not have health insurance, please complete below.
I,
, do swear, that I do not have a health insurance policy in
effect under my name, nor am I covered by the health insurance policy of anyone else or any group.
Has a claim been submitted to any other party or insurer? If YES, please provide details and a claim
reference number below.
YES
NO
Claim Reference Number
Claim Filing Instructions

Original evidence to show dates of departure and return travel (booking invoice, travel tickets,
itinerary etc.).

All original invoices/receipts for expenses incurred.

If a claim is submitted on behalf of the estate of a deceased insured, we will require certified copies
of the death certificate, together with Estate Letters of Administration. If the insured passed away
due to illness rather than the result of injury, we may require a medical certificate to be completed
by the deceased’s Primary Care Physician (PCP).

If a claim is being submitted as a result of injury, please provide a full description of the incident
leading up to the injury, and if another party was involved, please provide their details, including
insurance carrier information, if available.
PLEASE SEND DOCUMENTS AND KEEP COPIES FOR YOUR RECORDS
If you are unable to supply any of the documentation requested, please provide a written
explanation.
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InsureandGo USA – Emergency Medical / Dental Expense Claims Form
Please Answer All Questions
Date and Time
the injury / illness
occurred
Date:
Time:
Country and Town /
Province where injury /
illness occurred
Country:
Town/Province:
Full description of illness or injury and details of any other party involved:
Important – please number all receipts for expenses incurred and write the corresponding number in the
column headed 'Receipt No.' when completing the ‘Medical Expenses’ section below.
Have you previously suffered from the condition which resulted in the submission of this
claim, or any related condition? If answer is YES, we may require your PCP to complete a
medical affidavit.
YES
NO
Medical Facility
Date & Time
Admitted
Date:
Time:
Date & Time
Discharged
Date:
Time:
Medical Expenses
Receipt
No
Date of
Service
Description of Service
Service Provider
Total
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$ Amount
$
Paid
Y/N
InsureandGo USA – Emergency Medical / Dental Expense Claims Form
Other Insurance
Do you, or anyone else making a claim have any other insurance which may cover this
trip? (i.e. Private medical insurance, travel insurance through your credit card, tour
operator/travel agent.) If YES, please provide full details below:
Company
Street
Name
Address
State
City
Group #
Member
ID #
YES
NO
Zip
Policy #
Previous Claims
Have you or any person covered by this policy previously made a claim of this type under
any other travel insurance? If YES, please provide details below:
YES
Please proceed to the next page in order to complete Health Conditions Assessment
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NO
InsureandGo USA – Emergency Medical / Dental Expense Claims Form
Health Conditions Assessment
On the date of travel, purchase of the policy or booking of the trip, were you, or a traveling
companion whose condition has given rise to the claim:
Aware of any medical condition or set of circumstances which could reasonably be
YES
expected to give rise to a claim?
Having an on-going medical condition (or any medical complication directly
attributable to that condition) which was being investigated by a specialist or
YES
General Practioner? (If the condition was declared at the time of the policy,
please give details below.)
Having a medical condition directly or indirectly related to the condition for which
the claim is being made? (If the condition was declared at the time of the policy,
YES
please give details below.)
Having received or awaiting hospital tests or treatment for any condition or set of
YES
symptoms which had not yet been diagnosed?
NO
NO
NO
NO
Having been given a terminal prognosis?
YES
NO
Having been travelling for the purpose of obtaining medical treatment abroad?
YES
NO
Having been travelling against the advice of a medical practitioner?
YES
NO
Having received or awaiting treatment relating to a complication of pregnancy or
YES
NO
childbirth?
Was a letter concerning any of the above obtained from a treating Physician? If
YES
NO
YES, please forward a copy of the letter.
If YES was answered to any of the above please give further details of the condition or circumstance.
(Please note that we may need your physician to complete a medical certificate.)
Are you expecting to receive, or are you going to submit any further related
expenses?
If YES, please provide details (continue on a separate sheet if necessary):
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YES
NO
InsureandGo USA – Emergency Medical / Dental Expense Claims Form
STATE FRAUD WARNING LANGUAGE
Alabama
Delaware
"Any person who knowingly presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly
presents false information in an application for insurance
is guilty of a crime and may be subject to restitution,
fines, or confinement in prison, or any combination
thereof."
"Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, files a statement of claim
containing any false, incomplete or misleading
information is guilty of a felony."
Alaska
"A person who knowingly and with intent to injure,
defraud, or deceive an insurance company files 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."
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 benefits if false information materially
related to a claim was provided by the applicant." [DC
Code]
Florida
"Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim
containing any false, incomplete, or misleading
information is guilty of a felony of the third degree."
Arkansas
Idaho
"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 fines and
confinement in prison."
"Any person who knowingly, and with intent to defraud
or deceive any insurance company, files a statement
containing any false, incomplete or misleading
information is guilty of a felony."
California
"A person who knowingly and with intent to defraud an
insurer files a statement of claim containing any false,
incomplete, or misleading information commits a felony."
IN GENERAL: "For your protection California law requires
the following to appear on this form: Any person who
knowingly presents 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."
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, fines,
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 for insurance proceeds shall be reported
to the Colorado Division of Insurance within the
Department of Regulatory Agencies."
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Indiana
Kentucky
"Any person who knowingly and with intent to defraud
any insurance company or other person files 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."
Louisiana
"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 fines and
confinement in prison."
InsureandGo USA – Emergency Medical / Dental Expense Claims Form
Maine
Pennsylvania
"It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the
purpose of defrauding the company. Penalties may
include imprisonment, fines or denial of insurance
benefits."
"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 subjects such person to criminal and
civil penalties."
Maryland
"Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who
knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be
subject to fines and confinement in prison."
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, files 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 files 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."
Ohio
"Any person who, with intent to defraud or knowing that
he is facilitating a fraud against an insurer, submits an
application or files 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."
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Rhode Island
"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 of a crime and may be subject to fines and
confinement in prison."
Tennessee
"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, fines and denial of insurance benefits."
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."
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, fines and denial of insurance benefits."
Washington
"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, fines and denial of insurance benefits."
West Virginia
"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 fines and
confinement in prison."
InsureandGo USA - Emergency Medical / Dental Expense Claims Form
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."
Insured Signature:
Date:
AUTHORIZATION
The undersigned represents and warrants information or documents provided to InsureandGo USA by the undersigned prior to and after the
date of the application for insurance and the facts and other matters contained in the foregoing are true and accurate to the best of the
undersigned’s knowledge and belief.
Signature of Claimant 1:
Date:
Signature of Claimant 2:
Date:
Signature of Claimant 3:
Date:
Signature of Claimant 4:
Date:
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InsureandGo USA - Emergency Medical / Dental Expense Claims Form
Each person filing a claim must sign and date below.
Signature of Claimant
Date
Signature of Claimant
Date
Signature of Claimant
Date
Signature of Claimant
Date
Return the complete form via email, fax, or mail to:
E-mail: [email protected]
Fax: (877)570-9801
Insure & Go USA
Mail: 7300 Corporate Center Dr. Suite 601
Miami, FL 33126
For any questions please contact the below phone number.
Monday – Friday 9:00 AM to 5:00 PM EST
Phone: (888)491-4577
Insurance underwritten by American Commerce Insurance Company
Plan administered by Insure & Go Insurance Services USA, Corp
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