Insurance Accident Benefits Application

INSURANCE ACCIDENT BENEFITS APPLICATION

Applicant / Insured Information

Relationship to Insured/Claimant:

Policy and Coverage Details

Policy Period: From to

Accident and Loss Information

Date of Accident:   Time:

Medical Treatment and Expenses

Date first treated:   Hospitalized: Yes No

Income Replacement and Non-Medical Benefits

Available Benefits (Select all that apply)

Beneficiary Designation (for Death Benefits)

Secondary Beneficiary Name:   Percentage:

Documentation Checklist

Please attach copies of applicable documents. Check each item submitted or to follow:

Exclusions and Important Notices

Applicant acknowledges that benefits under this application are subject to the terms, conditions, exclusions and limits of the policy identified above. Benefits are not payable where loss or injury is excluded by policy provisions, policy cancellation prior to the date of loss, material misrepresentation, or where loss arises from intentionally self-inflicted injury, active participation in a criminal act, or fraud.

Applicant further acknowledges that payment of provisional benefits does not constitute acceptance of liability. The insurer reserves the right to investigate, require substantiating documentation, and to adjust, suspend, or recover benefits paid where payment was made in error or where third-party recovery reduces insurer liability.

Authorization, Certification and Subrogation

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any knowingly false or misleading statement made to obtain benefits may subject me to civil or criminal penalties and may void benefits under the policy.

I authorize any medical provider, employer, or other party possessing records relevant to this claim to release such records to the insurer, its agents, and representatives for the purpose of claim investigation, evaluation, and payment. I authorize the insurer to obtain and use medical and employment records as necessary to determine eligibility and benefit amounts.

I acknowledge the insurer's right of subrogation and assignment. To the extent benefits are paid, I assign to the insurer my rights of recovery against third parties responsible for the loss, and I will cooperate in the insurer's recovery efforts. I agree to execute documents necessary to protect the insurer's subrogation rights and to remit recoveries as required by law or policy.

Applicant Certification

By signing below I certify under penalty of perjury that the information provided in this application and any documents provided in support are true, accurate, and complete. I understand that the insurer may verify statements made herein and may deny or recover benefits for material misrepresentations or omissions.

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