Accident Protection Plan Claim Submission

UnitedHealthcare is committed to supporting you while you recover from your accident. is guide will assist you in initiating

your claim. Please review the following information carefully.

Follow these simple steps

1. Use the information checklist below to gather information needed to submit your claim. Have this information ready

when you call us. If someone makes the call for you, he or she will need to provide this information on your behalf.

2. Call us toll-free at 1-888-299-2070, TTY 711. Hours of operation are Monday through Friday, 8 a.m. – 6 p.m. ET.

3. Sign and date the Authorization Form located on the back of this page. Give your physician the signed and dated form.

Please also fax a copy of the signed, dated form to us at 1-888-505-8550.

What happens next

When you contact us at 1-888-299-2070, TTY 711, we will learn more about your specic request, guide you through

the claim process, answer your questions and tell you what to expect. You have our commitment to be responsive and

supportive during the claim process.

Information checklist

Please have the following information ready when you call:

 Employer’s name and location

 Your full name and Social Security number

 Your complete address and phone number

 Date of birth

 Marital status and number of dependents

 Last day you worked (if applicable)

 Hospital name and address, if applicable

 Description of your accident

 Physician’s name, address and phone number

 Date of treatment, if applicable

Accident Protection Plan Claim Submission

Submitting an Accident Protection Plan Claim

1. Gather information about your accident. Review the

Information Checklist for guidance.

2. Call UnitedHealthcare at 1-888-299-2070, TTY 711.

3. Complete and fax any necessary forms to UnitedHealthcare

at 1-888-505-8550.

Hours of operation are Monday through Friday,

8 a.m. – 6 p.m. ET.

DISCLOSURE AUTHORIZATION TO BE COMPLETED BY EMPLOYEE

Participant’s Name (Please Print):_______________________________________________

I AUTHORIZE: any doctor, physician, healer, health care practitioner, hospital, clinic, other medical facility, professional,

or provider of health care, medically related facility or association, medical examiner, pharmacy, pharmacy benefit

manager, employee assistance plan, insurance company, health maintenance organization or similar entity to

provide access to or to give Unimerica Life Insurance Company, Unimerica Life Insurance Company of New York,

UnitedHealthcare Insurance Company (Company) or the Plan Administrator or their employees and authorized agents

or authorized representatives, any medical and non-medical information or records that they may have concerning my

health condition, or health history, or regarding any advice, care or treatment provided to me. This information and/

or records may include, but is not limited to: cause, treatment diagnoses, prognoses, consultations, examinations,

tests, prescriptions, or advice regarding my physical or mental condition, or other information concerning me. This

may also include, but is not limited to, information concerning: mental illness, psychiatric, drug or alcohol use and any

disability, and also HIV related testing, infection, illness, and AIDS (Acquired Immune Deficiency Syndrome), as well

as communicable diseases and genetic testing. If my Plan Administrator sponsors both a disability plan underwritten

or administered by the Company and a medical plan of any type written by another UnitedHealth Group Company,

the information and records described in this form may also be given to any UnitedHealth Group Company which

administers such medical or disability benefits for the purpose of evaluating any claim that may be submitted by me or

on my behalf for benefits, for evaluating return to employment opportunities, and for administering any feature described

in the plan. This information may also be extracted for use in audits or for statistical purposes.

I AUTHORIZE: any financial institution, accountant, tax preparer, insurance company or reinsurer, consumer reporting

agency, insurance support organization, Claimant’s agent, employer, group policyholder, benefit plan administrator,

or governmental agency, including the Social Security Administration, to give the Company or the Plan Administrator

or their employees and authorized agents, or authorized representatives, any information or records that they have

concerning me, my occupation, my activities, employee/employment records, earnings or finances, applications for

insurance coverage, prior claims files and claim history, work history and work related activities.

I UNDERSTAND: the information obtained will be included as part of the proof of claim and will be used to determine

eligibility for claim benefits, any amounts payable, return to employment opportunities, and to administer any other

feature described in the plan with respect to the Claimant. This authorization shall remain valid and apply to all records,

information and events that occur over the duration of the claim, but not to exceed 24 months. A photocopy of this

form is as valid as the original and I or my authorized representative may request one. I or my representative may revoke

this authorization at any time as it applies to future disclosures, by notifying the Company in writing. The information

obtained will not be disclosed to anyone EXCEPT: (a) reinsuring companies; (b) the Medical Information Bureau,

Inc., which operates Health Claim Index (HCI); (c) fraud or overinsurance detection bureaus; (d) anyone performing

business, medical or legal functions with respect to the claim or the plan, including any entity providing assistance

to the Company under its Social Security Assistance Program and employers involved in return to employment

discussions; (e) for audit or statistical purposes; (f) as may be required or permitted by law; or (g) as I may further

authorize. A valid authorization or court order for information does not waive other privacy rights.

If my medical information contains information regarding drugs or alcohol abuse, I understand that my records may be

protected under federal (42 CFR Part 2) and some state laws. To the extent permitted under law, I can ask the party

that disclosed information to the Company to permit me to inspect and copy the information it disclosed. I understand

that I can refuse to sign this disclosure authorization; however, I understand that if I do so, the Company may deny my

claim for benefits pursuant to the plan. The use and further disclosure of information disclosed hereunder may not be

subject to the Health Insurance Portability and Accountability Act (HIPAA).

Signature of Claimant or

Claimant’s Authorized Representative:____________________________________ Date:

Relationship, if other than Claimant: ______________________________________

RETURN TO: UnitedHealthcare Specialty Benefits

PO Box 7140 Portland ME 04112-7140

Tel: 1-888-299-2070, TTY 711 Fax: 1-888-505-8550



cut here

If claimant does not sign this authorization and fails to obtain clariﬁcation of incomplete or inconsistent responses upon request, the claim may be denied.

29 C.F.R. §825.307(a). Claimant has the right to obtain a copy of this authorization after signed.

FRAUD WARNING NOTICES

Please review notice that applies in your state

For claimants in Alabama:

Any person who knowingly

presents a false or fraudulent claim

for payment of a loss or beneﬁt

or who knowingly presents false

information in an application for

insurance is guilty of a crime and

may be subject to restitution, ﬁnes,

or conﬁnement in prison, or any

combination thereof.

For claimants in Alaska:

A person who knowingly and with

intent to injure, defraud, or deceive

an insurance company ﬁles a claim

containing false, incomplete, or

misleading information may be

prosecuted under state law.

For claimants in 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.

For claimants in California:

UnitedHealthcare may terminate

your coverage and/or deny any

claim under the policy if it is

determined that you: knowingly,

and with actual intent to deceive,

presented false information

in this application; and such

statement was the basis for

UnitedHealthcare’s approval of your

coverage under the policy.

For claimants in 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.

For claimants in Connecticut:

Any person who knowingly

presents false information in an

application for insurance or life

settlement contract is guilty of a

crime and may be subject to ﬁnes

and conﬁnement in prison.

For claimants in Delaware:

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.

For claimants in 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.

For claimants in Florida:

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.

For claimants in 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.

For claimants in Idaho:

Any person who knowingly, and

with intent to defraud or deceive

any insurance company, ﬁles a

statement of claim containing any

false, incomplete, or misleading

information is guilty of a felony.

For claimants in Indiana:

A person who knowingly and with

intent to defraud an insurer ﬁles a

statement of claim containing any

false, incomplete, or misleading

information commits a felony.

For claimants in Kansas:

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 may be guilty of fraud

as determined by a court of law.

For claimants in 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 information

or conceals, for the purpose of

misleading, information concerning

any fact material thereto commits a

fraudulent insurance act, which is a

crime.

For claimants in 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.

For claimants in Maryland:

Any person who knowingly

or willfully presents a false or

fraudulent claim for payment for a

loss or beneﬁt or who knowingly or

willfully presents false information in

an application for insurance is guilty

of a crime and may be subject to

ﬁnes and conﬁnement in prison.

For claimants in Minnesota:

A person who ﬁles a claim with

intent to defraud or helps commit a

fraud against an insurer is guilty of

a crime.

UnitedHealthcare Accident Protection Plan is provided by UnitedHealthcare Insurance Company on Policy Form UHCAC-POL-1 (01/12). In Texas, it is

provided on Policy Form UHCAC-POL-1-TX (01/12). In New York it is provided by Unimerica Life Insurance Company of New York on Policy Form UHCAC-

POL-1-NY (01/12). UnitedHealthcare Insurance Company is located in Hartford, CT; Unimerica Life Insurance Company of New York in New York, NY. Some

products vary by state or may not be available in all states.

For claimants in 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.

For claimants in New Jersey:

Any person who knowingly ﬁles a

statement of claim containing any

false or misleading information is

subject to criminal and civil penalties.

For claimants in New Mexico:

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 civil ﬁnes and penalties.

For claimants in 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.

For claimants in Oklahoma:

WARNING: Any person who

knowingly, and with intent to injure,

defraud or deceive an insurer, makes

any claim for the proceeds of an

insurance policy containing any false,

incomplete or misleading information

is guilty of a felony.

For claimants in Oregon:

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 may

be guilty of a crime and may be

subject to ﬁnes and conﬁnement

in prison.

For claimants in 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.

For claimants in Tennessee

and Washington:

It is a crime to knowingly provide

false, incomplete or misleading

information to an insurance company

for the purpose of defrauding

the company. Penalties include

imprisonment, ﬁnes and denial of

insurance beneﬁts.

For claimants in 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.

For claimants in Vermont:

Any person who knowingly and with

intent to injure, defraud, or deceive

any insurer ﬁles a statement of claim

or an application containing false,

incomplete, or misleading information

may be guilty of a crime.

For claimants in Virginia:

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 false, incomplete, or

misleading information may have

violated state law.

For claimants in All Other

States: 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.

FRAUD WARNING NOTICES

Please review notice that applies in your state continued…