The Texas Clm 2 form is a Student Accident Claim Form designed for parents and guardians to report injuries sustained by students during school-related activities. This form is essential for filing claims with the insurance provider, ensuring that medical expenses related to the injury can be addressed. For assistance in completing the form, please click the button below.
The Texas Clm 2 form serves as a vital tool for parents and guardians seeking to report and claim benefits for student accidents that occur during school-related activities. This form is divided into two main sections: the first section is intended for completion by a school official, while the second section must be filled out by the parent or guardian. In the first section, essential details such as the name of the school, the injured student's information, and specifics about the incident—including the time, location, and nature of the injury—are documented. The second section requires the parent or guardian to provide personal information, insurance details, and an authorization for the release of medical information. It is important to note that the school is not responsible for medical payments; rather, this form facilitates claims under a supplemental accident insurance policy that may cover costs exceeding a family’s primary insurance. The process emphasizes the need for timely submission within 90 days of the injury and outlines the steps to ensure that all necessary documentation is provided to support the claim. Understanding the components and requirements of the Texas Clm 2 form is crucial for navigating the claims process effectively.
STUDENT ACCIDENT CLAIM FORM
SUBMIT CLAIM FORM TO: Fidelity Security Life Insurance Company c/o Universal Fidelity Life Insurance Company P.O. Box 304
Duncan, OK 73534-0304 (800) 366-8354
Section 1 - Notice of Injury
(To be completed by School Official)
(This section may be completed by parent if 24-Hour coverage was purchased and accident is not school-related)
Name of School District:
Name of School:
School Phone No:
Name of Injured Student:
□ Male
□ Female
Grade:
Date of Injury:
Time of Injury:
□ AM
□ PM
Part of Body Injured:
□ Right Side
□ Left Side
Under whose supervision?
Was accident witnessed?
□ Yes
□ No
If "Yes", by whom?
The accident happened while the student was participating in:
□ Interscholastic UIL Activity
□ Non Interscholastic UIL Activity
Specify Sport/Activity:
Explain in detail how and where the injury occurred: ___________________________________________________________________________
__________________________________________________________________________________________________________________________
Signature of School Official: ________________________________________________________________________________________________
(Title)
(Date)
IMPORTANT INFORMATION ON REVERSE SIDE
Section 2 - Parent/Guardian Statement (To be completed by Parent/Guardian)
Name of Student:
Date of Birth:
Home Phone No:
Is student covered by any insurance plan? □ Yes □ No
If yes,
Policy No.
Parent/Guardian Name:
Relationship to Student:
Address: _________________________________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Father's Name:
Father's Employer:
Name of Father's Insurance Company (must be completed - If Father has no insurance - write "None"):
Insurance Company:
Mother's Name:
Mother's Employer:
Name of Mother's Insurance Company (must be completed - If Mother has no insurance - write "None"):
Name of Insurance Company:
I hereby authorize any insurance company, their authorized agent, hospital, physician, employer, school official or other person who has attended or examined the claimant to disclose when requested to do so all information with respect to any injury, policy coverage, medical history, consultations, prescription or treatment, and copies of all hospital or medical records, and itemized bills. A photo static copy of this authorization shall be considered as effective and valid as the original. I swear that the above information is true and correct to the best of my knowledge. I further understand that any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
__________________
_____________________________________________
______________________________________________________
(Print Name of Student)
(Signature of Parent/Guardian)
Form CLM-2 (10)
ATTENTION PARENTS
Dear Parents,
Below are instructions for filing the Claim Form. Should you have any questions, contact the school trainer or call the number listed below. The school is NOT responsible for medical payment for your child. The school may have purchased a supplemental Accident Only Policy which may cover charges in excess of your own insurance policy. If you have no other insurance for your child, this policy may pay first or primary. This is a limited benefit policy and may not cover all medical bills for your child. Any charges not covered are YOUR RESPONSIBILITY.
For all school-related accidents, be sure to contact the school trainer or administrator.
INSTRUCTIONS FOR FILING THE CLAIM FORM
Section 1 must be completed by a school official for all school-related accidents and by the parent / guardian if 24-Hour coverage was purchased and the accident is not school-related.
Section 2 must be completed by the parent / guardian.
How to File A Claim
Step 1 - Complete and submit the claim form to the Claims Office at the address indicated below or send electronically to [email protected]. The claim form must be submitted within 90 days from the date of injury regardless of whether you have other insurance or not. Keep a copy of the claim form for your records and present a copy of the claim form to the provider or facility. DO NOT RELY on the provider or facility to submit the claim form.
Submit copies of itemized bills to the address indicated below. Itemized bills are original bills you receive, not monthly statements. Itemized bills are often called UB92 or HCFA1500 forms that provide the procedure code, diagnosis code, and the Providers’ address and Tax ID Number.
Step 2 - File a claim with your primary insurance first. insurance is your family and/or group insurance coverage.
Submit copies of all bills to your primary insurance first. Your primary The school’s policy is supplemental to all other valid coverage.
Step 3. After receiving payment or copies of Explanation of Benefits (EOB) from your family and/or group insurance, submit a copy of this claim form along with copies of your itemized bills and EOBs from your primary insurance company to the address below:
Fidelity Security Life Insurance Company c/o Universal Fidelity Life Insurance Company
P.O. Box 304
Duncan, OK 73534-0304
(800) 366-8354
Texas Kids First has unique access to one of the most creative innovations in the insurance industry – the Texas Kids First Provider Network (TKF Network)* – the first “no balance bill” non-profit network of providers in the State. The network consists of medical professionals and hospitals that have agreed to treat injured students from our insured districts for the services paid and outlined in the Schedule of Benefits of the Texas Kids First Student Accident Plans when the student patient has no other insurance.
Please refer to the website www.texaskidsfirst.com or call 1-800-366-8354 for a list of contracted providers in your area and to verify full assignment acceptance.
*The TKF Network is made available by Texas Kids First and is not affiliated with Fidelity Security Life Insurance Company.
FRAUDULENT CLAIM DISCLOSURE
Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Filling out the Texas Clm 2 form is an important step in processing a student accident claim. Follow the steps carefully to ensure that all necessary information is provided. Once the form is completed and submitted, the claims office will review it to determine eligibility for coverage based on the details provided.
Once both sections are completed, submit the claim form to the address provided. Keep a copy for your records and ensure that all necessary bills are attached. Follow up with your primary insurance to ensure proper processing of the claim.
The Texas CLM 2 form, also known as the Student Accident Claim Form, is a document used to report and claim benefits for injuries sustained by students during school-related activities. It is primarily designed for parents or guardians to provide necessary information about the incident, the injured student, and any applicable insurance coverage. This form must be submitted to Fidelity Security Life Insurance Company to initiate the claims process.
The form consists of two sections. Section 1 must be completed by a school official for school-related accidents. However, if 24-hour coverage has been purchased and the injury is not school-related, a parent or guardian can complete this section. Section 2 is specifically for the parent or guardian to fill out, providing details about the student and their insurance coverage.
To submit the claim form, follow these steps:
It is important not to rely on the medical provider to submit the claim form on your behalf.
To complete the Texas CLM 2 form, you will need to provide various details, including:
Accurate and thorough information will help expedite the claims process.
If the student is covered by another insurance plan, it is essential to file a claim with that primary insurance first. After receiving payment or an Explanation of Benefits (EOB) from the primary insurance, you can then submit the Texas CLM 2 form along with copies of the itemized bills and EOBs to Fidelity Security Life Insurance Company. This ensures that any remaining eligible expenses can be processed under the school’s supplemental policy.
Submitting a fraudulent claim is a serious offense. If a person knowingly presents false information or a fraudulent claim, they may face legal consequences, including fines and potential imprisonment. It is crucial to provide truthful and accurate information when completing the Texas CLM 2 form to avoid any legal issues.
Incomplete Information: Failing to fill out all required fields can delay the processing of your claim. Make sure every section is complete.
Incorrect Signature: The form must be signed by the appropriate person. Ensure that the parent or guardian signs in Section 2.
Missing Documentation: Not including necessary documents, such as itemized bills or Explanation of Benefits (EOB), can result in a denial of your claim.
Wrong Submission Method: Submitting the claim form to the wrong address or via the wrong method can cause delays. Always double-check the submission instructions.
Failure to Meet Deadlines: Claims must be submitted within 90 days of the injury. Missing this deadline can result in a denial.
Not Following Up: After submitting the claim, it is important to follow up. Not doing so may lead to unresolved issues.
Inaccurate Insurance Information: Providing incorrect details about existing insurance coverage can complicate the claim process.
Assuming Providers Will Submit Claims: Do not rely on medical providers to submit the claim for you. Always submit your own claim form.
When filing a claim using the Texas Clm 2 form, there are several other forms and documents that may also be required to support the claim process. Understanding these documents can streamline your experience and ensure that you have all necessary information at hand.
Gathering these forms and documents can enhance the efficiency of the claims process and improve the likelihood of a successful outcome. Always ensure that you submit all required documentation in a timely manner to avoid delays in processing your claim.
The Texas Claim 2 form is similar to the Student Health Insurance Claim Form. Both documents require detailed information about the injured student and the circumstances surrounding the injury. They serve to initiate the claims process for medical expenses incurred due to accidents. The Student Health Insurance Claim Form focuses on medical coverage provided by health insurance, while the Texas Claim 2 form specifically addresses coverage related to school-related incidents. Both forms emphasize the importance of accurate and truthful information to avoid complications in the claims process.
Another comparable document is the Accident Claim Form used in personal injury cases. This form also collects information about the injury, the injured party, and the circumstances leading to the incident. While the Texas Claim 2 form is tailored for students injured during school activities, the Accident Claim Form can be used in various contexts, including workplace or recreational injuries. Both documents aim to gather necessary details to support a claim for compensation, ensuring that the injured party receives appropriate medical coverage.
The Medical Expense Claim Form is another document that shares similarities with the Texas Claim 2 form. This form is utilized to claim reimbursement for medical expenses incurred due to an injury. Like the Texas Claim 2, it requires information about the patient and the nature of the injury. However, the Medical Expense Claim Form is often used for broader medical claims, while the Texas Claim 2 form is specifically designed for incidents occurring in a school setting. Both forms require itemized bills and supporting documentation to process claims effectively.
The Insurance Claim Form for Minor Injuries is also akin to the Texas Claim 2 form. This document is designed for situations involving less severe injuries where immediate medical attention may not be necessary. While the Texas Claim 2 form addresses injuries that may require extensive medical treatment, both forms facilitate the claims process for medical expenses related to injuries. They require similar information, including the injured party's details and the nature of the incident, to ensure that claims are processed in a timely manner.
Lastly, the School Accident Report Form has a close relationship with the Texas Claim 2 form. This document is typically completed by school officials to document the details of an accident involving a student. While the School Accident Report Form focuses on the incident itself, the Texas Claim 2 form is used to claim insurance benefits for medical expenses resulting from that incident. Both forms are essential for maintaining accurate records and ensuring that students receive the necessary support following an accident.
When filling out the Texas Clm 2 form, it's important to follow specific guidelines to ensure your claim is processed smoothly. Here are five things you should and shouldn't do:
Understanding the Texas Clm 2 form is crucial for parents and guardians navigating student accident claims. However, several misconceptions can lead to confusion. Here are five common misunderstandings:
By addressing these misconceptions, parents can better navigate the claims process and ensure they are adequately prepared for any potential expenses related to their child's injury.
Filling out and using the Texas CLM 2 form requires careful attention to detail. Here are key takeaways to ensure a smooth process:
By following these guidelines, parents and guardians can effectively navigate the claims process for student accidents in Texas.