Lifemap Accident Claim Form PDF

Statement of Accident
Claim Filing Instructions
This Statement of Accident includes the forms required to apply for Voluntary Accident benefits. Please read
this instructions carefully before submitting to LifeMap.
Have you…
1) Completed the Insured’s Statement?
a) Incomplete, unsigned, or undated statements will delay your claim
2) Signed and dated the Authorization for Release of Information?
3) Had your Employer complete, sign and date the Employer's Statement?
a) The Employer’s Statement must be returned to you upon completion
4) Had the physician treating you sign and date the Attending Physician’s Statement?
a) The Attending Physician’s Statement must be returned to you upon completion
5) Attached copies of all itemized bills* (not EOBs) related to this accident?
a) Bills must include date(s) of services, diagnosis code(s), procedure code(s) and change(s)
6) Included a copy of any motor vehicle incident/accident and/or police report?
*If the medical bills do not include all the requested information, please submit a complete copy of the patient’s medical
records with your claim. Additional medical information may be requested to evaluate your claim.
For Oregon Accident Policies, please note: Effective January 1, 2014, in compliance with Oregon state law, benefits for
covered ambulance transportation will be paid directly to the provider of the ambulance transportation.
You are responsible for ensuring all forms are completed and returned to our office. Our review of your
claim will not begin until we receive all sections completed.
Forms can be sent to LifeMap via:

You are responsible for ensuring all
Email: [email protected]
forms are completed and returned to
Fax: (855) 733-4615 our office along with the required
documentation. If a form is
Regular Mail: LifeMap Assurance Company
received incomplete, unsigned or
Attn: Life and Disability Claims Department
undated, it will be returned to you
PO Box 1271, M/S E8L
for completion, delaying the claim.
Portland, OR 97207-1271
If you have any questions, please call the LifeMap Life and Disability Claims Department at 1 (800) 286-1129.
ACCIDENT CLAIM (4/14) Page 1 of 9 8/15

Insured’s Statement
Information about Patient
Name of Patient (Last, First, Middle Initial) Date of Birth Patient’s Social Security Number
Male
Member Spouse Domestic Partner Dependent Child Female
Mailing Address Street & Number City State Zip Primary Phone Number
( )
Information about Employee/Primary Insured

Name of Member, if not the patient (Last, First, Middle Initial) Date of Birth Social Security Number
Mailing Address Street & Number City State Zip

Male Female
Home Phone Number Cell Phone Number Employer/Association Policy Number

( ) ( )
Information regarding the Accident
Date of Accident Time of Accident Location of Accident
AM PM
Please describe in detail the events leading up to the accident and how the accident happened. If you need more space,
please attach a separate sheet of paper. If the accident involved a motor vehicle, attach a copy of the incident/accident/traffic
report.
Dates unable to work due to this accident (if applicable):

From: Through:
Is the accident the result of any of the following? (please check all that apply)
Participation in a felony Bacterial infection Illegal or fraudulent work or employment
Intentionally self-inflicted injuries Participation in war Commission of a crime
Parachuting, bungee jumping, hang Service in the armed forces of Operating or riding in any kind of aircraft
gliding, motor vehicle race or any country A work-related accident
contest Participation in a riot Illness
Being intoxicated or under the None of the above
influence of any narcotic
Information about Physicians and/or Hospital
Full name of treating physician Specialty
Mailing Address (street, city, state, zip) Phone Number Fax Number
( ) ( )
Full name of primary physician Specialty
( ) ( )
Full name of referring physician/hospital
( ) ( )
Acknowledgement
I certify that the answers I have made to the above questions are complete and true to the best of my knowledge and belief. I
acknowledge that I have read the fraud notice on page 3 of this form.
 
Employee’s Signature Date
Please complete page 4.

Insurance Fraud Warning

Unless specific state language is provided below, the following general fraud notice applies: Any person who
knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
California Residents: For your protection California law requires the following to appear on this form: Any person who
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
Colorado Residents: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an
insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company
who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Residents: W ARNING: It is a crime to provide false or misleading information to an insurer for
the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Residents: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or
employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading
information is guilty of a felony of the third degree.
Hawaii Residents: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for
payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading
information is subject to criminal and civil penalties.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
Puerto Rico Residents: Any person who knowingly and with the intention to defraud includes false information in an
application for insurance or file, assist, or abet in the filing of a fraudulent claim to obtain payment of a loss or other
benefit, or files, more than one claim for the same loss or damage, commits a felony and if found guilty shall be
punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars
($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail
term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be
reduced to a minimum of two (2) years.
Arkansas, Louisiana, Maryland, New Mexico, Rhode Island and West Virginia Residents: Any person who
knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Maine, Tennessee, Virginia and Washington Residents: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.
Alaska, Kansas and Oregon Residents: Any person who knowingly provides false, incomplete, or misleading
information to an insurance company for the purpose of defrauding the company may be guilty of a crime. Penalties
may include imprisonment, fines, and denial of insurance benefits.
Delaware, Idaho, Indiana and Oklahoma Residents: Any person who knowingly, and with intent to injure, defraud or
deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a
felony.

Authorization to Obtain and Release Information

I authorize persons or entities having any records or knowledge of me or my health, including any licensed
physician, any other medical practitioner or provider, pharmacist, hospital, clinic, other medical or medically related
facility, federal, state or local government agency, insurance or reinsuring company, consumer reporting agency or
employer:
To give Medical information including chart notes, x-rays, operative reports, lab and medication records and all
other medical information about me, including medical history, diagnosis, testing, test results and prognosis with
respect to any physical or mental condition and/or treatment of me, excluding psychotherapy notes, and including,
but not limited to, any other mental or psychiatric records, medical, dental and hospital records which may have been
acquired in the course of examination or treatment.
If the information to be disclosed contains any of the types or information listed below, additional laws relating to the
use and disclosure may apply. I understand and agree that this information will be used or disclosed only if I place
my initials in the applicable space next to the type of information:
Drugs/Alcohol diagnosis, treatment or referral information
Mental Health information – including provider notes
HIV/AIDS information
Genetic Testing Information
To LifeMap Assurance Company (LifeMap) and to its authorized representatives.
• I understand that the information obtained by use of this authorization will be used by LifeMap and authorized
representatives to evaluate and adjudicate my current claim, and may be re-disclosed to (a) any medical,
investigative, financial or vocational specialist or entity, or (b) any other organization or person, employed by or
representing LifeMap solely to assist with the evaluation and adjudication of my current claim.
• I understand that LifeMap complies with state and federal laws and regulations enacted to protect my privacy. I
also understand that the information disclosed to LifeMap may be subject to redisclosure and may no longer be
protected under the Health Information Portability and Accountability Act (HIPAA).
• I understand that I have the right to revoke this authorization by notifying LifeMap in writing, of my revocation.
However, such revocation is not effective to the extent that LifeMap has relied previously upon this authorization
for the use or disclosure of my protected health information. In addition, I understand that m y revocation of, or
my failure to sign this authorization may impair the ability of LifeMap to evaluate m y current claim and as a result
may be a basis for denying that current claim for benefits.
• I acknowledge that I have read this authorization. I understand and agree that this authorization shall remain in
force for the duration of my claim(s) or 12 months, whichever occurs first. A photocopy or facsimile of this
authorization is as valid as the original. I understand that I, or my authorized representative, have the right to
request and receive a copy of this authorization and the information to which it pertains.
 
Patient’s Full Name (please print clearly) Date Signed
 
Patient’s Signature (or Parent/Guardian) Relation to Patient

Attending Physician’s Statement
This statement must be filled-in completely by a physician without expense to the insurance company.
Patient Information
Name of Patient (Last, First, Middle Initial) Social Security Number Date of Birth
Name of Primary Insured, if not the Patient Social Security Number Employer Name
Information about Diagnosis

Diagnosis ICD Code(s)
Date of Accident Time of Accident Location of Accident
Dates of Treatment:
Dates patient was unable to work due to this accident (if applicable):
From: Through:
Is this condition due to immediate physical damage to the body which…
Results directly from an unexpected and unintentional event? Is independent of disease, bodily infirmity or any other cause?
Yes Yes
No No
For fracture(s) or dislocation(s), please indicate: For lacerations, please indicate the length (in inches):
Closed Reduction
Open Reduction
None
For surgical procedures, indicate: For burns, indicate the degree:
Inpatient First
Outpatient Second
The type of surgical procedure(s) and date(s) performed: Third
Indicate total square inches of body surface burned:
Please describe in detail the events leading up to the accident and how the accident happened. If you need more space,
please attach a separate sheet of paper.

Attending Physician’s Statement (continued)

Is the accident the result of any of the following? (please check all that apply)
Participation in a felony Bacterial infection Illegal or fraudulent work or employment
Intentionally self-inflicted injuries Participation in war Commission of a crime
Parachuting, bungee jumping, hang Service in the armed forces of Operating or riding in any kind of aircraft
gliding, motor vehicle race or contest any country A work-related accident
Being intoxicated or under Participation in a riot Illness
the influence of any narcotic None of the above
Information about Hospital, Intensive Care Unit or Rehabilitation Unit Confinement

Hospital Admission Date and Time: Discharge Date and Time:
Intensive Care
Unit Rehabilitation
Hospital or Facility Name Phone Number
( )
Mailing Address (street, city, state, zip) Fax Number

( )
Information about Physician

Physician’s Name (Please Print) Degree/Specialty Phone Number
( )
Office Address City State Zip Fax Number

( )
Acknowledgement
 
Attending Physician’s Signature Date
Please return completed form to your patient.


knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines
and confinement in state prison.
who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award
payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Residents: W ARNING: It is a crime to provide false or misleading information to an insurer for
the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an
insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Residents: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or
employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading
information is guilty of a felony of the third degree.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person
files an application for insurance or statement of claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a
crime shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for
each such violation.
application for insurance or file, assist, or abet in the filing of a fraudulent claim to obtain payment of a loss or other
benefit, or files, more than one claim for the same loss or damage, commits a felony and if found guilty shall be
punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars
($10,000); or imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail
term may be increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be
reduced to a minimum of two (2) years.
Arkansas, Louisiana, Maryland, New Mexico, Rhode Island and West Virginia Residents: Any person who
knowingly presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information
in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Alaska, Kansas and Oregon Residents: Any person who knowingly provides false, incomplete, or misleading
information to an insurance company for the purpose of defrauding the company may be guilty of a crime. Penalties
may include imprisonment, fines, and denial of insurance benefits.
felony.

Employer’s or Administrator’s Statement

Information about Employee
Employee Name (Last, First, Middle Initial) Job Title Social Security Number Class
Date Employed: Date Employee Last Worked Before the Accident: Date of Termination:
N/A
Reason for stopping work: Disability Dismissed Resigned Layoff Retired

Family Medical Leave of Absence Other Leave of Absence Other Reason
Date returned to work: If part-time, number of hours If employee has not returned to work,
Full-time: Part-time: worked per week: estimated return to work date:
Regularly scheduled hours per week: Please indicate which days of the week this employee is normally scheduled to work.
(check) Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Please describe primary job duties:
Employee’s Earnings: $ Was the Accident due to employment?

Earnings prior to increase $ Yes No Unsure
Date of last increase:
hourly weekly monthly annual Has Workers’ Compensation claim been filed?
commission shift differential bonuses other: Yes No Not yet
If Workers’ Compensation claim has been filed, was it: Approved Denied Pending
Information about Employee’s Accident Insurance Coverage
Employee’s Voluntary Accident coverage: Dependent’s Voluntary Accident Coverage:
Effective Date: Termination Date: Effective Date: Termination Date:
Additional Documentation (Please attach a copy of the following documents to this form.)
 The employee's Workers' Compensation claim(s) and Approval/Denial Notification, if applicable
Information about Employer
Employer Name Location Code (if applicable) Group Policy Number
Employer Mailing Address Street & Number City State Zip Phone Number
( )
Name and title of employer representative completing this form Email Address
Acknowledgement
 
Employer Representative’s Signature Date


knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement
of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.
who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose
of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from
insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the
purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer
may deny insurance benefits if false information materially related to a claim was provided by the applicant.
Florida Residents: Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee,
insurance company, or self-insured program, files a statement of claim containing any false or misleading information is
guilty of a felony of the third degree.
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information, or conceals for the purpose
of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime shall
also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such
violation.
application for insurance or file, assist, or abet in the filing of a fraudulent claim to obtain payment of a loss or other benefit,
or files, more than one claim for the same loss or damage, commits a felony and if found guilty shall be punished for each
violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or
imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be
increased to a maximum of five (5) years; and if mitigating circumstances are present, the jail term may be reduced to a
minimum of two (2) years.
Arkansas, Louisiana, Maryland, New Mexico, Rhode Island and West Virginia Residents: Any person who knowingly
presents a false or fraudulent claim for payment for a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Alaska, Kansas and Oregon Residents: Any person who knowingly provides false, incomplete, or misleading information
to an insurance company for the purpose of defrauding the company may be guilty of a crime. Penalties may include
imprisonment, fines, and denial of insurance benefits.
felony.

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Statement of Accident

Claim Filing Instructions

Forms can be sent to LifeMap via:

ACCIDENT CLAIM (4/14) Page 1 of 9 8/15

Information about Employee/Primary Insured

Mailing Address Street & Number City State Zip

Home Phone Number Cell Phone Number Employer/Association Policy Number

Dates unable to work due to this accident (if applicable):

Please complete page 4.

Insurance Fraud Warning

ACCIDENT CLAIM (4/14) Page 3 of 9 8/15

Authorization to Obtain and Release Information

ACCIDENT CLAIM (4/14) Page 4 of 9 8/15

Information about Diagnosis

Date of Accident Time of Accident Location of Accident

ACCIDENT CLAIM (4/14) Page 5 of 9 8/15

Attending Physician’s Statement (continued)

Information about Hospital, Intensive Care Unit or Rehabilitation Unit Confinement

Mailing Address (street, city, state, zip) Fax Number

Information about Physician

Office Address City State Zip Fax Number

Please return completed form to your patient.

ACCIDENT CLAIM (4/14) Page 6 of 9 8/15

Insurance Fraud Warning

ACCIDENT CLAIM (4/14) Page 7 of 9 8/15

Employer’s or Administrator’s Statement

Reason for stopping work: Disability Dismissed Resigned Layoff Retired

Employee’s Earnings: $ Was the Accident due to employment?

ACCIDENT CLAIM (4/14) Page 8 of 9 8/15

Insurance Fraud Warning

ACCIDENT CLAIM (4/14) Page 9 of 9 8/15

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