GrouProtector Claim Forms

All claims for occurrence of accidental death, specific loss (loss of limb, hand, sight, etc.) or injury during a plan sponsored event or activity must be submitted to the special risks claims department using a special risks claim form.

Which claim form should I use?

Life and AD&D coverage
In the event of a death or specific loss (loss of limb, hand, sight, etc.), the insured will be required to submit a Nationwide Life and AD&D claim form (PDF). This form must be submitted along with the appropriate Primary, Excess or Volunteer Fire claim form. Complete and mail the forms as specified.

Primary coverage
If an insured holds a Primary Plan insurance policy, all original claims will be submitted to Nationwide Insurance first. A Nationwide primary plan claim form (PDF) will need to be completed and mailed as specified.

Excess coverage
If the insured holds an Excess Plan policy, all claims will be submitted to the insured's primary carrier first. Any approved balance not covered by the primary carrier will be paid by Nationwide Insurance according to the benefit limits stated in the insurance policy. A Nationwide excess plan claim form (PDF) will need to be completed and mailed as specified.

Volunteer fire and emergency coverage
If a loss or injury occurs while on duty for or during volunteer fire or emergency sponsored events/activities, a volunteer fire claim form (PDF)  will need to be completed and mailed as specified.

Volunteer fire and emergency coverage (Indiana)
If a loss or injury occurs while on duty for or during volunteer fire or emergency sponsored events/activities, a volunteer fire claim form (Indiana) (PDF)  will need to be completed and mailed as specified.

Disability coverage
If disability coverage is included in the summary of benefits for the policy holder's contract and a valid incident for disability has occurred, a disability claim form (PDF) will need to be completed and mailed as specified.

When should I file a claim?

Written notice of a claim must be received within 20 days of a loss or injury. Written proof of the loss or injury (the completed claim form and supporting documents) must be submitted to the claims department within 90 days of the occurrence.

How do I complete the claim form?

• All questions must be answered in full for efficient claims processing.
• Section I must be completed and certified by an official of the plan sponsor's organization. Policy number must be included.
• Section II must be completed by the insured (parent or guardian if minor).
• Date and sign Section III (optional)
• Attach itemized bills showing the (a) patients 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 to:
Nationwide Specialty Health
PO Box 420
Springfield, MA 01101

Or

Fax to:
1-413-214-7761

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