Accident Medical Brochures, Claim and ACH Forms

GrouProtector^SM brochures and applications

Learn more about GrouProtector and get an application:

File a group accident medical claim

Claims for any injury, illness, accidental death or specific loss (limb, hand, sight, etc.) during a group-sponsored activity must be submitted using the correct claim form.

Which claim form should you use?

Primary medical accident coverage

Plan sponsors with primary medical accident coverage must submit a completed claim form to Nationwide Insurance first: 
Nationwide primary plan claim form

Excess medical accident coverage

Plan sponsors with excess medical accident coverage must submit their claim to the insured’s primary insurance company first. Any covered expenses not covered by the primary insurance company must be submitted secondarily via a completed claim form to Nationwide Insurance: 
Nationwide excess plan claim form

Volunteer emergency group coverage

Injuries, death or specific losses (limb, hand, sight, etc.) that occur during a group-sponsored activity must be completed and submitted to Nationwide Insurance: 
Nationwide volunteer emergency group claim form

Volunteer emergency group coverage (Indiana)

Injuries, death or specific losses (limb, hand, sight, etc.) that occur during an Indiana volunteer emergency group-sponsored activity must be completed and submitted to Nationwide Insurance: 
Volunteer emergency group claim form (Indiana)

Death and specific loss coverage

In the event of a death or specific loss (loss of limb, hand, sight, etc.) the plan sponsor must complete and submit a claim form to Nationwide Insurance along with the appropriate primary, excess or volunteer claim form: 
Nationwide Death and Specific Loss claim form

When should you file a claim?

Written notice of a claim must be received within 20 days of a loss or injury. The completed claim form and supporting documents must be submitted to the claims department within 90 days of the occurrence using the instructions on the claim form.

How do you complete the claim form?

• Answer all questions in full for efficient claims processing.
• Ask an official of the plan sponsor's organization to complete and certify Section I.
• Have the insured (parent or guardian if the insured is a minor) complete Section II.
• Date and sign Section III (optional).
• Attach itemized bills showing the (a) patient’s name, (b) diagnosed condition, (c) date(s) of treatment, (d) nature of treatment and (e) charge per treatment.

Send all documentation to the address or fax number listed below:

Mail 
Nationwide Specialty Insurance 
PO Box 420 
Springfield, MA 01101 

Fax 
413-214-7761

Get accident medical ACH forms

Using an ACH (Automated Clearing House) form  is a convenient way to pay initial premiums, policy endorsements and even routine bills.

To make a single payment from a checking or savings account, complete the appropriate ACH form and submit it along with your new application, billing statement or policy endorsement. Remember, account and routing numbers are required to process the payment. 

Nationwide policies

To issue premium payment for a Nationwide policy instead of mailing a check or money order, use the Nationwide ACH form. 

National Casualty policies

To issue premium payment for a National Casualty Company (a division of Scottsdale Insurance) policy, please use the National Casualty ACH Form.

Fax completed ACH forms and any supporting documentation detailing the premium due to: 
1-413-214-7761 
Attention: Policy Administration