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Filing a GrouProtector^SM 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 I 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 (PDF)

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  (PDF)

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 (PDF)

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) (PDF)

Death & 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 & Specific Loss claim form (PDF)

When should I 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 I complete the claim form?

• Answer all questions in full for efficient claims processing.
• An official of the plan sponsor's organization must complete and certify Section I.
• The insured (parent or guardian if the insured is a minor) must 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
1-413-214-7761

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