CLAIM REPORT for
Group Accident & Sickness Insurance                                       PRINT OUT AND MAIL TO:

 

AMERICAN INCOME LIFE INS.
PO BOX 50158
INDIANAPOLIS, IN 46250


To be completed by the Group Leader                               Phone: 1-800-849-4820  Fax: 1-317-849-2793            

POLICY #                Serial Number  
Dates Person was Insured    
Name of Group     Policyholder 
 
For prompt service please attach Physician/Emergency Room Report  and all itemized bills for medical services rendered (doctor, hospital and prescriptions).
 
Patient Name    Age   Sex      
Address    
City   State   Zip  
Camper/Member      Counselor    Eligible for Workers Comp    Summer Staff    Volunteer Leader
             

Injury Report

Illness Report

Date of Injury  Time

Date of Symptoms
Group Activity  Nature of Illness
How and Where Injury Occurred
Was Condition Present Before Became Insured?   Yes   No
Describe Injuries If Yes, Please Explain

Was the injury or illness reported to a staff member during the insured period? Yes   No

 
VERIFICATION SIGNATURE -- UNRELATED TO PATIENT
I hereby certify that this was a supervised group activity sponsored by the organization covered under this policy.
I was the:  program director, chaperone, group leader, other (please define)  
 
SIGNED: Phone:   Organization:
 
 
ASSIGNMENT FORM
I hereby authorize the American Income Life Insurance Company to pay benefits on the above claim to:
 
Medical Provider(s)      OR      
  Bills ARE PAID -- Reimburse: Address 
Address
Verified by: Position: Date: