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Proof of Loss     Coaches Injury Report         Fraud Statement    

 

Injury and Insurance Claim Page

Please Note

The League's insurance is a secondary insurance for those with their own personal insurance and a primary insurance for those without insurance.  A $100 deductible may apply for those claims processed as a primary claim.  The League is not responsible for this $100 deductible.

The hardest part of about tackle football is the injuries and then the insurance claim process.  I hope the information on this page helps and if not please call me at 906-779-5068.

WHEN TO FILE A CLAIM

Our policy is an EXCESS MEDICAL EXPENSE BENEFIT, YOU MUST FIRST FILE THE CLAIM WITH YOUR EXISTING INSURANCE PLAN.  If you do not have any other available insurance coverage you must fill out PROOF OF LOSS of the claim form and indicate "NO" in response to each insurance question, if appropriate.  You MUST sign the insurance portion of the form if you have no other coverage.  Please remember that this is a signed and sworn legal document.  (A $100 deductible may apply)

Tell the health care provider that there is a secondary claim insurance company.

Give this form to the Health Care Provider as it will start the process.  POLICY

HOW TO FILE A CLAIM

Step 1.  Document the injury.  Have the head coach or other league official fill out the  INJURY REPORT.

Step 2.  Complete a PROOF OF LOSS form.  This must be completed by the injured person or parent/guardian if a minor. 

Step 3.  Copies of fully itemized bills.  An itemized bill is usually in the HCFA-1500 or UB-92 format which means the bill should have a date of service, patient name, billing address and phone, provider tax identification number, procedural codes, and diagnosis code.

Step 4.  Copies of your insurance's Explanations Of Benefits (EOB).  When your insurance company processes the charges, they will send you an Explanation of Medical Benefits, or "EOB".  You must forward a copy of the Explanation of Benefits for EACH CHARGE.

Step 5.  Make sure you sign all forms and then mail all material to me:

Dean Lefebvre

141 Northview Dr.

Iron Mountain, MI 49801

I will then fill out Part 1 of our insurance claim form and mail the packet.

To see the full instruction page you can click here  Instruction Page