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Accidental Death and Dismemberment Claim Form Accidental Death and Dismemberment Claim Form

Accidental Death and Dismemberment Claim Form Accidental Death and Dismemberment Claim Form 2026

Accidental Death and Dismemberment Claim Form Accidental Death and Dismemberment Claim Form Preview on Page 1

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4.8 out of 5

180 votes

The document provides detailed instructions on how to file a dismemberment and loss of use claim with Nationwide Mutual Insurance Company. It outlines the necessary steps for claimants, including completing forms, obtaining a physician's statement, and submitting the claim to the appropriate administrator. Additionally, it includes legal notifications regarding fraud, privacy practices under HIPAA, and the handling of personal health information. The document emphasizes the importance of accurate information to avoid delays in processing claims.

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Click ‘Get Form’ to open the Accidental Death and Dismemberment Claim Form in the editor.
Begin by completing the Claimant Section on the front of the form. Fill in your name, Social Security number, date of birth, and relationship to the insured.
Read and sign the Authorization and Legal notice section located on the back of the form to ensure compliance.
Have your doctor complete the Physician’s Statement on the back of this form. Ensure they provide their contact information for verification.
Answer all questions thoroughly. Missing information can delay your claim process. Be sure to check if there is a new address.
Describe how the accident occurred in detail, and attach any supporting documents such as an accident report.
Finally, forward this completed form to your Administrator at the address provided at the top of the form.

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2014	4.8 Satisfied (180 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How do I file an add claim?

ADD policies provide financial protection against accidental death or injury, but can have a variety of exclusions. These can include intentional self-inflicted injuries, deaths resulting from natural causes, and injuries from illegal activities.

What does accidental death and dismemberment coverage cover?

For ADD claims, submit the following items. Operative reports and hospital records. Police or incident report. Medical examiners report with autopsy and toxicology. Any additional information deemed necessary during Guardians investigation.