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Central UP Youth Football League |
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Insurance Forms Certificate of Insurance Iron Mountain Kingsford Iron River 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 906-396-2186. 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. To help speed up your claim you can give a copy of our Claim Form to the Health Care Provider. This may eliminate the need to send in the EOB's or itemized bills. HOW TO FILE A CLAIM Coaches fill out the Injury report Form. Injury Report Form Parents or Guardian must Complete a 2010 Season - Proof of Loss I cannot start the claim until I have these two (2) forms. Make sure you sign all forms and then mail them to me: Dean Lefebvre (906-396-2186) 141 Northview Dr. Iron Mountain, MI 49801 I will then fill out Part 1 of our insurance, the Claim Form and fax the packet. Parents Please Note: You can provide your Health Care Provider with a copy of the Claim Form. If you give the Claim Form to the health Care Provider they will send the EOB's and itemized bill to our insurance company directly. You may have to provide the following information so start to collect the following: 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. 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.
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