Gerber Life Insurance Forms

PART 1-A – TO BE COMPLETED IN FULL BY THE ORGANIZATION/SCHOOL

Organization/School District Name Policy Number

School/Team/League Name Phone No.

Address Email

Type of Activity/Sport

If Athletics, designate

P.E. Class Intramural Interscholastic Game Jr. Varsity Varsity

Youth Adult Practice Other

Date of Accident Accident Time Date of First Treatment

Where and how did accident occur? (Please be specific)

Part of body Injured

At the time of the accident, was the claimant involved in a sponsored and supervised activity and were they a current student/member of the Organization/School District? Yes No

Under whose supervision? Was he/she a witness? Yes No

PART 1-B – TO BE COMPLETED IN FULL BY CLAIMANT – OR BY PARENT/LEGAL GUARDIAN IF CLAIMANT IS A MINOR

Claimant’s Name Social Security #

Date of Birth Age Grade Level Male Female

Claimant is a Student Player Coach Official/Umpire Volunteer Day Care Participant CE Student

Address of Claimant or Parents/Guardian

Phone No. Email Address

Name and Address of Family Physician

Phone No. Has treatment been completed? Yes No

Claimant or Father/Guardian Name

Employer Name and Address Phone No.

Self Employed Unemployed

Claimant or Mother/Guardian Name

Employer Name and Address Phone No.

Self Employed Unemployed

Is claimant covered under any other medical and or dental insurance policy? Yes No

Is claimant covered under a government sponsored insurance such as Medicare/Medicaid? Yes No

Name of all companies providing claimant insurance coverage or prepaid health plans

Are benefits due for this claim under these other insurance coverages? Yes No

Does your son or daughter have medical insurance coverage as an eligible dependent from a previous marriage as mandated in a divorce decree? Yes No

If yes, please give name, address and phone number of responsible party

AFFIDAVIT

I verify that the above statement on other insurance is accurate and complete. I understand that the intentional furnishing of incorrect information via the U.S. Mail may be fraudulent and violate federal laws as well as state laws. I agree that it is determined at a later date that there are other insurance benefits collectible on this claim I will reimburse Gerber Life Insurance Company to the extent for which Gerber Life Insurance Company would not have been liable.

SIGNATURE IS REQUIRED

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize any employer, health plan, insurance company, hospital, physician, health care profession, clinic, laboratory, pharmacy, medical facility or other person that has provided treatment, payment, or services in connection with this claim to disclose, when requested to do so, all information with respect to any injury, policy coverage, medical history, consultations, prescription or treatment, and copies of all hospital or medical records and itemized bills to WebTPA, Inc. and Gerber Life Insurance Company, it’s agents, employees and representatives.

I hereby authorize WebTPA, Inc. to discuss any information related to medical expenses incurred or treatments rendered in connection with this claim, with Special Markets Insurance Consultants, Inc. representatives and their assigned agents and to officials at the school or organization through which this policy is issued. A photo static copy of this authorization shall be considered as effective and valid as the original.

PLEASE READ

PLEASE FOLLOW THESE INSTRUCTIONS TO FILE A CLAIM

ALL INFORMATION MUST BE PROVIDED IN ORDER FOR CLAIM TO BE PROCESSED

NOTE: The accident policy benefits are limited and may not provide 100% coverage. Completion of a claim form does not guarantee benefit payment. Each claim is reviewed according to the policy provisions.