Fillable Primary Medical Expense Claim Form (Trip Preserver online claims)

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Primary Medical Expense Claim Form (Trip Preserver online claims)

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The Primary Medical Expense Claim Form (Trip Preserver online claims) form is 2 pages long and contains:

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  • 6 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

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Primary Medical Expense
Claim Form
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 210316OJUFE4UBUFT
Toll Free Phone: (8) 8 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
To be Completed by Insured / Guest
Name of Insured / Guest Reservation #
Address Work Phone # Home Phone #
Date of Birth (mm/dd/yy) E-mail Address
Date of Initial Trip Deposit (mm/dd/yy) Scheduled Departure Date (mm/dd/yy) Scheduled Return Date (mm/dd/yy) Date Incident Occurred (mm/dd/yy)
Name and Address of Property Management Company Phone #
Fax #
Name of leaseholder on the rental property and list all guests occupying the property
Name of Patient Relationship to Insured / Guest
Are you a U.S. Citizen? Date symptoms rst appeared (mm/dd/yy)
Give Nature of Sickness or Injury (Diagnosis) Date of initial treatment for this condition (mm/dd/yy)
Describe fully how, when and where Sickness / Injury Occurred
Was there previous treatment for these conditions prior to purchase of plan? Yes No If yes, when?
Name and address of primary care physician where you reside Physician’s Phone # Physician’s Fax #
Name and address of other physician(s) who treated the condition Physician’s Phone # Physician’s Fax #
Name and address of Hospital (if hospitalized) Date Admitted and Discharged Hospital Phone #
Was an accident report led for this incident? If yes, please provide a copy.
Note: Your Travel Insurance Policy is Primary to any other health, medical, and travel insurance you may have.
Do you have any other medical Insurance?
Please list all of your other medical insurance plans (group health, Medicare, supplemental, etc.)
Arch-2014
Yes No
( ) ( )
( )
( )
( ) ( )
( ) ( )
( )
Yes No
Yes No
Primary Medical Expense
Claim Form
Claims Department:
Red Sky Claims, C/O Arch Insurance Company
Executive Plaza IV, 11350 McCormick Road, Suite 102, Hunt Valley, MD 210316OJUFE4UBUFT
Toll Free Phone: (8) 8 | Fax: (443) 279-2901 | E-mail: redsky@archinsurance.com
Any person who knowingly presents a false or fraudulent claim for payment of loss or benet or
knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to nes and connement in prison.
Please include the following items with your claim forms after completing page 1 of this form. Any
omitted items will delay processing. You may want to send any valuable documents by certied mail.
3 Your cancelled check or credit card statement for the initial trip deposit.
3 Copies of explanation of benets from the primary carrier and all medical bills incurred while on your trip from your
other insurance in the form of standard UB and HCFA billing statements.
3 Completed and signed claim form
3 Copy of rental agreement
3 Credit card statement, cancelled checks, or cash receipt for all medical payments while on your trip
3 If Claimant is other than leaseholder, please provide a signed written statement from leaseholder listing all guests
occupying the rental property.
Claimed Expenses
_________________ Total amount paid for all medical treatment received while on trip (Attach all invoices)
_________________ Total amount reimbursable from other sources (Attach all responses received)
_________________ Total amount being claimed from Red Sky
Authorization to Disclose Information
Trip Preserver Product is Underwritten by Arch Insurance Company.
To any medical care provider, medical care facility, Insurer, government-sponsored health plan, or employer: I authorize the release of any
medical information about me to Arch Insurance Company, or its authorized representative. This applies to all information about the diagno-
sis, treatment, or prognosis of any illness or injury I now have or have had in the past. The Company will use this information to determine if
my claim is eligible. Any information obtained will not be released by the Company except to my primary health insurance carrier (if any) or
persons or organizations performing investigative or legal services for the Company in connection with my claim. A copy of this authorization
shall be considered as eect and valid as the original and shall remain in eect for one year from the date of authorization. I certify that the
information given by me in support of my claim is true and correct.
Patient’s or Authorized Representative’s Signature Date
If Authorized Representative, Relationship to Patient
or Legal Designation
Assignment of Benets
I Authorize the Claims Administrator, to pay benets in connection with this claim directly to the doctor, hospital, or other provider.
Patient’s or Authorized Representative’s Signature Date
If Authorized Representative, Relationship to Patient
or Legal Designation
Arch-2014
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Primary Medical Expense Claim Form (Trip Preserver online claims)

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Completed 12 September 2021

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