CAPITAL DISTRICT ASSOCIATION HOME PAGES
INSURANCE INFORMATION
IMPORTANT INSTRUCTIONS HOW TO FILE YOUR MEDICAL CLAIM

1. You have been provided with claim forms that are pre-filled with some of the important
information that is needed to process your claim efficiently. Please use this form only.

2. Section I must be filled out completely.

3. Section II is to be completed, signed, and dated by the claimant or parent/guardian of
the claimant.

4. Include all itemized bills for related medical expenses being claimed. These bills
must show the patients name, condition begin treated (diagnosis), type of treatment
received, date the expense(s) was/were incurred.

5. A deductible will apply to each claim.

6. A League Representative or Insurance Coordinator must sign Claim Form.

INSURANCE FORMS
2013 Initial Injury Report
(this form must be completed for any injury occurring at a CDPW event)
2013 Request for Certificate of Insurance
(complete this form to request a Certificate of Insurance, form may be mailed to the
CDPW Insurance Coordinator at the PO Box 212, Delmar, NY 12054)
Insurance Claim Form and Instructions
2013 Medical Claim Form
(Please complete this form as described on the included instructions.)
NOTE:
This coverage is in excess of all other group medical coverage. Please complete in
full the attached Other Insurance Inquiry and provide copies of the other
insurance’s Explanation of Benefits for each corresponding Itemized Bill. Failure
to provide this form, completed in its entirety, will delay claim processing.
Mail FULLY COMPLETED Claim Form to:
HSR Plaza II
4100 Medical Parkway
Carrolton TX 75007
Phone (972) 512-5600 Fax (972) 512-5820
Toll Free (866) 345-0973
E-Mail gisclaims@hsri.com
For questions, inquiries and/or status of your claim call (866) 345-0973