Trustmark Accident Insurance Claim: A Comprehensive Guide

TRUSTMARK INSURANCE COMPANY ACCIDENT CLAIM FORM

This form must be filled out by the attending physician and the policyholder, then submitted to us for claim evaluation.

If you are filing for the Accident Disability Benefit, the Employer section must be completed as well.

All fields must be filled in completely and legibly; incomplete or unreadable information could delay claim processing. Make sure to keep a copy of this form and any related documents for your records.

The policyholder must ensure the form is fully completed without any costs to Trustmark Insurance Company.

FRAUD WARNING!

Any person who knowingly and with the intent to defraud an insurance company files a claim or provides information that is false, incomplete, or misleading could be charged with insurance fraud, which is a crime.

GUIDELINES:

• Sections A & B: These must be filled out by the policyholder.
• Section C: This must be completed by the attending physician treating you for the injury or disability.
• Section D: To be completed by your employer if you’re claiming Accident Disability Benefit.

State-Specific Fraud Warnings: Provided for your information.
Authorization for Disclosure: You must sign and date this form. Give a copy to your physician.

Include any additional documentation that might help Trustmark evaluate your claim.

SECTION A:

• Policy/Certificate Number:
• Policyholder’s Name:
• Patient’s Name and Date of Birth:
• Relationship to Policyholder: [ ] Spouse [ ] Child [ ] Self [ ] Other
• Policyholder’s Address:
  • Street, City, State, ZIP Code
• Contact Information:
  • Home Phone, Work Phone, Date of Birth, Social Security Number

SECTION B: POLICYHOLDER’S STATEMENT

Fill out this section and attach itemized copies of any relevant bills, including those from medical providers, emergency rooms, hospitals, or motor vehicle incident reports. Ensure these bills contain diagnostic information.

• Accident Date:
• First Treatment Date:
• Describe the location of the accident and what happened to you:
• Primary Care Physician:
  • Phone Number, Street, City, State, ZIP Code
• Hospitalization:
  • Were you hospitalized? [ ] Yes [ ] No
  • If yes, provide the hospital’s name, phone number, address, and dates of hospitalization.

Statement of Accuracy:
I certify that the information on this claim form is correct and complete. I acknowledge the fraud notices included in this document.

Signature of Claimant:
Print Name:
If signed by someone else on behalf of the claimant, specify the relationship and provide Power of Attorney documentation, if applicable.
Date Signed

SECTION C: ATTENDING PHYSICIAN’S STATEMENT

SECTION D: EMPLOYER’S STATEMENT

• Employer’s Information:
  • Name, Phone Number, Street, City, State, ZIP Code
• Employee’s Job Details:
  • Job Title, Average Hours Worked Weekly, Annual Salary, Last Day Worked
• Work-Related Information:
  • Was the accident work-related? [ ] Yes [ ] No
  • Has the employee filed for Workman’s Compensation? If yes, provide the workman’s compensation carrier’s details.
  • Has the employee been terminated? If yes, when?
• Signature of Employer:
• Print Name and Title:
• Date Signed:

Fraud warnings 

Also read: Hartford Accident Insurance Payout

Disclosure Authorization Form

Insured’s Name (please print): ______________________________

Authorization for Disclosure

I authorize any doctor, hospital, clinic, healthcare provider, insurer, reinsurer, consumer reporting agency, insurance support organization, insurance agent, employer, financial institution, Social Security Administration, Internal Revenue Service, Veterans Administration, or other relevant individuals or organizations to release my health and personal information to Trustmark Insurance Company, its affiliates, or any authorized consumer reporting agency.

This includes details about:

• Medical conditions, including cause, treatment, diagnosis, prognosis, consultations, examinations, tests, and prescriptions related to my physical or mental health.
• Occupational information, including employment history, earnings, or financial data, as needed to assess policy claims or benefits.

This authorization also covers data on HIV infection, immune system disorders (including AIDS), driving records, mental illness, alcohol or drug use.

Additionally, I authorize the Social Security Administration to share relevant records with Trustmark Insurance Company or its designated representatives for claim processing or benefit continuation.

This can involve:

• Earnings details from the last 10 years.
• Overview of total earnings.
• Information on benefit awards, denials, or continuations.

Revocation Policy

I can revoke this authorization in writing by sending a signed and dated notice to Trustmark Insurance Company.

I agree that Trustmark Insurance Company can use the obtained information to assess policy claims and benefits.

A photocopy of this authorization is as valid as the original. I can request a copy at any time.

This authorization remains in effect for the policy term or up to 12 months from the date signed. Revoking or refusing to sign this authorization might impact claim handling, possibly leading to benefit denial.

I also authorize Trustmark Insurance Company and its affiliates to report any past or current claims to ICS.

Special Notes for Specific States:

• Montana Residents: You can request a record of subsequent information disclosures.
• New Mexico Residents: You must revoke this authorization within 10 days of receipt by Trustmark Insurance Company. This applies to confidential abuse information.
• Florida Residents: Knowingly filing a false or misleading insurance claim or application with intent to defraud is a third-degree felony.
• New York Residents: Filing an insurance claim or application with false or misleading information with intent to defraud is a crime, subject to penalties up to $5,000 plus the stated claim value for each violation.

Signature and Date
Date: _______________________
Signature: ___________________________________________________
Date of Birth: //______
Relationship (if other than the insured): _____________________