To file a GrouProtector claim, please provide a written notice of your claim within 20 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.
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.
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.
Please submit claims to Nationwide, not to the patient’s other plan(s).
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 make your payment and submit an Explanation of Benefits. 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 but IN)
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
- Have the group’s official complete Section I, which asks for details about the accident or sickness. 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.
- Have the patient (parent or guardian, if minor) complete Section II, which asks for information about the patient.
- Have the patient (parent or guardian, if minor) complete Section III (optional). This section authorizes us to pay claims directly to the doctor, hospital or other supplier.
- Have the patient (parent or guardian, if minor) complete the authorization form (optional). This form gives us permission to disclose health information to designated family, friends and others involved in the patient’s health care.
- Attach itemized bills showing the patient’s name, diagnosed condition, date(s) of treatment, nature of treatment and charge per treatment.
- Include the Explanation of Benefits from the primary insurance carrier, if applicable.
- Send all documentation to us.
Nationwide Specialty Insurance
PO Box 420
Springfield, MA 01101
How to check the status of a claim
Call the claims department at 1-800-525-8669. 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