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Participant Accident Statement of Claim for Travel, Activity ... 2026
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- Click ‘Get Form’ to open the Participant Accident Statement of Claim in the editor.
- Begin with Part I – Policyholder’s Statement. Fill in all required fields including Policy Number, Policyholder Name, and contact details. Ensure this section is signed by the Official Representative.
- Proceed to Part II – Claimant’s Statement. Indicate whether the claimant is the Insured/Participant or Policyholder. Complete all relevant fields such as Claimant Name, DOB, and Social Security Number.
- In the Information About the Claim section, check all applicable benefits claimed and provide detailed descriptions for each claim type, including dates and reasons for cancellations or delays.
- Attach any Required Attachments as specified in Section D. This may include itineraries or proof of payment depending on your claim type.
- Review all sections for completeness before signing the Important Notice at the end of the form. Retain copies of submitted documents for your records.
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CLAIMS REPORTING: Written notice must be submitted to Claims Administrators within 30 days after a covered loss occurs. Phone: (972) 492-6764; Fax: (972) 492-
Each participant must report on the claim form submitted to the claims processor any other health and accident insurance coverage which the participant mayRead more