Before using the generic form below, check with your school district, organization, or their websites, for any special instructions or special claim forms that are used to submit a claim. Organizations such as USSSA, USASA, AABC, AYF/AYC, USA Judo, Babe Ruth Baseball, USA Field Hockey, or USYSA may have claim forms that have been customized for their activities and specific instructions for levels of claim validation before the claim is sent to K&K.
Download Participant Accident Incident Form
How to submit a participant accident incident report or claim:
- An incident report or the claim form designed for your organization should be submitted as soon as possible following the injury that required medical attention. Policies have timely filing requirements which vary based on the policy and the state in which it is written.
- Be sure to check with your organization for any special instructions on how to file a claim. Some organizations require that the incident report or claim form is reviewed by the organization for claim validation before it is forwarded to K&K.
- Make certain that the incident report or claim form is completed in its entirety, including the policy number, with accurate and detailed injury information and how the accident happened.
- The incident report or claim form MUST BE SIGNED by a representative of the insured. Again, check the website for your organization for any special instructions on where to send the form if another signature besides a representative of the insured is required. INCIDENT REPORTS WHICH ARE NOT SIGNED, WILL DELAY THE CLAIM.
- The incident report or claim form must be accompanied by the Other Insurance Questionnaire or some other form providing information about other insurance. If there is no other insurance and you are not a Medicaid recipient, it would be beneficial to have something in writing from your employer that you or your child are not covered under insurance offered at work.
- If there is primary insurance, all medical providers should be informed of the primary insurance information so they are billed first, and the K&K insurance information so they are billed second. If this is done, the medical providers will bill all parties with the itemized billing forms that have diagnosis and procedure codes.
- If medical bills are sent in by the patient, they should be CMS1500 forms for physician charges and UB04 forms for hospital/facility charges. If there is primary insurance, these itemized bills must also be accompanied by the primary insurance Explanation of Benefits (EOB).
- If surgeon charges are submitted, the operative report is not always required, but can be helpful.
Download Participant Accident Incident Form
