File a claim

Photo credit: Marshall Garlington

This policy provides excess accident medical coverage for injuries sustained while participating in a covered activity or covered travel as defined by the policy. Medical bills must be submitted to all other valid and collectible insurance plans prior to submitting to this plan for consideration. Health Special Risk, Inc. (HSR) will consider benefits according to the terms and conditions of the policy after other available insurance has processed the claim. Please read the following to expedite the claims process.

WOMEN’S FLAT TRACK DERBY ASSOCIATION (WFTDA)
INJURY/INCIDENT REPORT FILING INSTRUCTIONS

  • Within 14 days of your injury, fully complete the enclosed claim form and return to WFTDA: Injury reports received after the allowable deadline will not be eligible for claims. All claim forms must be approved by WFTDA for consideration of claims.

    Complete and submit the online injury form below, within 14 days of the date of injury. If you have any questions prior to submitting the online form, contact .

    WFTDA Insurance will verify coverage and submit a copy of the claim form to Health Special Risk, Inc.

  • Health Special Risk, Inc. will send notification to claimant of receipt of claim.
  • Note: Coverage is excess over any other valid and collectible insurance and consideration will be made according to the termsand conditions of the policy.
    • Deductible: $2,500 per injury deductible for participants with primary medical insurance and $7,500 per injury forparticipants WITHOUT primary medical insurance. The deductible is corridor meaning eligible medical expensesmust exceed the noted level before consideration of payment.
    • Treatment must commence within 30 days from the date of injury.
    • Benefit Period: 52 weeks from the date of accident.

CLAIM FILING INSTRUCTIONS

  1. Submit initial injury report using the online form, below, within 14 days of the injury. WFTDA must verify your eligibility or your claim will not be processed. Do not send injury reports directly to Health Special Risk! This will delay the process.
  2. Incomplete claim forms are one of the most frequent reasons claim payments are delayed. Answer and complete the sectionregarding “PART II – OTHER INSURANCE STATEMENT”, marking either “yes” or “no”, and signing the line for authorization.By marking “yes”, this will allow HSR to communicate with the doctors/hospital(s) concerning your claim to expedite the claims process.
  3. To streamline the process, please notify all doctors/hospitals of all available health insurance, as well as, the excess accidentmedical coverage. Provide them PAYOR # 65449 for HSR billing. This will allow the medical provider to forward the itemizedbills directly to HSR. If you have already received treatment related to injury and did not know about this coverage, thenplease send all statements/itemized bills to HSR at the address shown below.
    Note: An itemized bill includes dates of treatment, physician’s or hospital’s name, address, and Tax I.D number, diagnosiscode(s), and procedure codes. Balance Due statements are NOT acceptable.
  4. In addition to the itemized bill(s) copies of the corresponding Explanation of Benefits(s) from other valid and collectibleinsurance showing their claim consideration are required to consider charges.
  5. Benefits are paid to directly to the medical provider(s) unless a payment receipt is received.

    HEALTH SPECIAL RISK, INC, HSR PLAZA II
    4100 MEDICAL PARKWAY
    CARROLLTON, TX 75007
    CUSTOMER SERVICE: 866-523-3199 7:.00 AM to 7:00 PM CST


    Part 1 - Injury Information










    Parent/Guargian Contact Info









    AthleteOfficialCoachSpectatorEmployeeVolunteerOther

    SingleMarried
    Dental Claims (if applicable)


    Whole, Sound & NaturalFilledCappedArtificial
    Medical Claims


    YesNo


    PracticePre-GameDuring GamePost GameWhile TravelingOther

    Part 2 - Other Insurance Statement















    Part 3 - Authorization to Pay Benefits to Provider

    I authorize medical payments to physician or supplier for services described on any attached statements enclosed.



    I hereby authorize any insurance company, hospital, physician 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, consultation, prescription or treatment, and copies of all hospital or medical records. A photo static copy of this authorization shall be considered as effective and valid as the original.



    By entering your name above, you are signing this claim form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this claim form.


    FRAUD STATEMENTS

    FOR RESIDENTS OF ALL STATES OTHER THAN THOSE LISTED BELOW:

    Any person who knowingly presents a false or fraudulent claim for payment of 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 and Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false, incomplete or misleading information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may be prosecuted under state law.
    Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
    Arkansas, Louisiana, Maryland, West Virginia & Rhode Island: Warning: Any person who knowingly presents a false or fraudulent claim for payment of 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.
    California: For your protection California law requires the following to appear on this form: Any person who knowingly presents a 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: 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.
    Connecticut: This form must be completed in its entirety. Any person who intentionally misrepresents or intentionally fails to disclose any material fact related to a claimed injury may be guilty of a felony.
    Delaware, Idaho, Indiana: 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.
    District of Columbia: 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: WARNING :Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
    Hawaii: 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.
    Georgia: Any natural person who knowingly or willfully
    1)Makes or aids in the making of any false or fraudulent statement or representation of any material fact or thing:
    a)In any written statement;
    b)In the filing of a claim; or
    c)In the receiving of money for an application for a policy of insurance for the purpose of procuring or attempting to procure the payment of any false orfraudulent claim or other benefit by an insurer;
    2)Receives money for the purpose of purchasing insurance and converts such money to such persons own benefit;
    3)Issues fake or counterfeit insurance policies, certificates of insurance, insurance identification cards, or insurance binders; or
    4)Makes any false or fraudulent representation as to the death or disability of a policy or certificate holder in any written statement for the purpose of fraudulently obtaining money or benefit from an insurer commits the crime of insurance fraud.
    Maine: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines, or a denial of insurance benefits.
    Michigan, North Dakota, South Dakota: Any person who knowingly and with intent to defraud any insurance company or another person files a 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 the person to criminal and civil penalties.
    Minnesota; A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
    Nevada: Any person who knowingly files a statement of claim containing any misrepresentation or any false, incomplete or misleading information may be guilty of a criminal act punishable under state or federal law, or both, and may be subject to civil penalties.
    New Hampshire: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
    New Jersey: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
    New Mexico and Pennsylvania: 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.
    New York: 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 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.
    Ohio: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
    Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
    Oregon: Warning: Any person who knowingly, and with intent to defraud any insurance company or other persons 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, may be subject to prosecution for insurance fraud.
    Tennessee, Virginia, Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
    Texas: Any person who knowingly presents a 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.