146 Metlars Lane, Piscataway, NJ 08854 | T: (732) 562-1990 | F: (732) 562-1399 | firstname.lastname@example.org
Student Accident Insurance coverage is purchased by every school in the Diocese for each enrolled student.
The plan is underwritten by United States Fire Insurance Company, and is administered by Bollinger Insurance. The plan in effect provides coverage on an excess basis only, thus only those medical expenses which are NOT payable by your own personal or group insurance are eligible for coverage under this policy up to the limits.
Some important reminders when filing a claim:
1. Claim forms must be mailed to Bollinger within 90 days of the accident date. *Policy # is MCB5859639
Please be sure that:
a) The school official has completed his/her section of the claim form.
b) You have completed and signed the Parentʼs Statement and Medical Authorization.
c) The Statement of Other Insurance section must be fully completed*.
*If you are employed but have no insurance, please include a statement of verification from your employer on their letterhead.
2. IMMEDIATELY submit a claim for all medical expenses to the company that administers your personal or group insurance (including Major Medical coverage). If you have coverage through an HMO or similar facility, you must use this facility first or your claim will not be covered under this policy.
3. After your primary insurance has paid the medical expenses up to the policy limits, submit Itemized Bills AND copies of the Explanation of Benefits from your primary insurance company as you receive them and mail to the address shown below. We cannot accept balance due bills.
4. Please write the claimantʼs name, policy number, and date of accident on all Bills and Explanation of Benefits.
5. Please keep a copy of this Claim Form, all bills, and primary insurance Explanation of Benefits for your own records.
6. If you need further information, call 866-267-0092. DO NOT CALL THE SCHOOL.
146 Metlars Lane
Piscataway, NJ 08854
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T: (732) 562-1990
F: (732) 562-1399