Group accident medical claims

Send completed claim form to:

K&K Insurance Group, Inc.
PO Box 2338
Fort Wayne, IN 46801

Email: kk.paclaims@kandkinsurance.com
Fax: 1-312-381-9077

How to file a GrouProtectorSM claim

To file a GrouProtector claim, please provide a written notice of your claim within 30 days of a loss or injury that occurs during your group-sponsored activity. Then follow up with a completed claim form and supporting documents within 90 days of the incident. (Timelines may be longer in certain states.)

Keep in mind that you don’t need to file a separate claim for each bill. Just file one claim for each incident. If you receive more bills after you file your claim, include your group’s name, policy number and patient’s name when you send them to us.

Group accident medical claim forms

Primary medical accident coverage claim form

A primary plan is the first plan to pay claims after a covered event. Payments from other insurance coverage may be reduced as needed.

Excess medical accident coverage claim form

An excess plan is the last plan to pay claims after a covered event. After paying for deductibles and copays from the patient’s other plans, any remaining charges will be considered after you receive your Explanations of Benefits from your other insurance carriers and make your payment. If no other insurance exists, please include a written statement from the patient or parent’s employer(s) stating that no other coverage exists.

Please submit claims to the patient’s primary insurance company first.

Death and specific loss coverage claim form

If a group participant passes away or suffers a specific loss, such as loss of limb, sight or hearing, please include this form, along with the appropriate primary or excess claim form.

Volunteer emergency group claim form (all states except Indiana)

Please use this form for volunteer emergency groups outside of Indiana. This form covers injuries, death and specific losses, such as loss of limb, sight or hearing.

Volunteer emergency group claim form (Indiana)

Please use this form for volunteer emergency groups in Indiana. This form covers injuries, death and specific losses, such as loss of limb, sight or hearing.

How to complete the claim form

  1. Have the group’s official complete Section I, which asks for details about the accident. The official cannot be the agent, broker or anyone related to the patient. If applicable, proof of membership or certificate of coverage may be submitted in place of a signature. 
  2. Have the patient (parent or guardian, if minor) complete Section II, which asks for information about the patient.
  3. (Optional) Have the patient (parent or guardian, if minor) complete Section III. This section authorizes us to pay claims directly to the doctor, hospital or other supplier. 
  4. (Optional) Have the patient (parent or guardian, if minor) complete the authorization form . This form gives us permission to disclose health information to designated family, friends and others involved in the patient’s health care.
  5. Attach itemized bills showing the patient’s name, diagnosed condition, date(s) of treatment, nature of treatment and charge per treatment.
  6. Include all Explanations of Benefits from other insurance carriers, if applicable.
  7. Send all documentation to us.
Mail
K&K Insurance / Specialty Benefits
PO Box 2338
Fort Wayne, IN 46801
 
 
Fax
1-312-381-9077

How to check the status of a claim

Call the claims department at 1-800-237-2917, and say “medical.” If all representatives are busy, leave a detailed message including:
  • Group's name
  • Phone number with area code
  • Patient’s name
  • Member number, if applicable
  • Claim number

Each claim is handled on the basis of its individual facts and circumstances and in accordance with policy language, including applicable exclusions, conditions and limitations, as well as applicable controlling law. Insurance overview is for informational purposes only and does not replace or modify the definitions and information contained in individual insurance policies or declaration pages, which are controlling. Terms and availability vary by state and exclusions apply.