REIMBURSEMENT AGREEMENT
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- Bartholomew Stokes
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1 REIMBURSEMENT AGREEMENT EMPLOYEE: SSN# PATIENT: GROUP: Plumbers & Pipefitters Medical Fund (L5) AM0040 I, hereby agree to provide information and whatever other assistance is requested to help the Plan Administrators of my employer sponsored health plan, and/or their properly authorized representatives, in pursuing the subrogation and/or coordination of benefit rights (as detailed in the health plan documents) which arise as a result of the accident which occurred on involving and, the injuries received in this accident and the medical care received to treat the injuries. I specifically acknowledge that I have read and understand the terms of the Plan and specifically agree to each of the following: 1. To provide information requested and if I do not have it, make reasonable efforts to obtain it; 2. To ask my doctor(s) and/or hospital where I have received treatment to release information concerning my condition and treatment to the Plan Administrator and/or their authorized representative(s) as requested; 3. To submit to physical examination upon request of the Plan Administrator and/or their authorized representative(s). 4. NOT to sign any releases or waivers presented to me by representatives of the party causing the accident or his/her insurers without obtaining consent of the Plan Administrator or otherwise compromise or jeopardize the Plan s subrogation rights; and 5. To notify the Plan Administrator if I should decide to bring a lawsuit against the party causing the accident and to instruct my attorney to keep the Plan Administrator informed of the status of my case. 6. I hereby agree to reimburse the Plan from any payment I may receive to the full extent of the amounts the Plan has paid without regard to the characterization or purpose for the payment and without offset for legal fees or other expenses incurred in securing the payment. Further,
2 I understand and agree that the Plan is not obligated to pay claims, payment for which may be delayed, withheld, or denied unless I cooperate in full and sign this Reimbursement Agreement. 7. I understand that the Plan expects reimbursement in full for all claims paid resulting from the accident even if I am not made whole by the payment. 8. By accepting benefits in excess of $300 from the Fund for an injury for which another person may be liable, I agree to file a claim for benefits under any source including any and all applicable policies of insurance, including but not limited to my homeowner insurance, automobile insurance or any liability policy held by me. Signed this Day of, 20 Group Name Signature Required:
3 SUBROGATION FORM COMPLETED FORM TO BE RETURNED TO: TELEPHONE NUMBER Carday Associates, Inc. (410) Columbia Gateway Drive, Suite A Columbia, MD Information About Accident Name of Employee: Social Security Number: : Telephone No.: Name of Person Injured: Relationship to Employee: Date of Birth of Person Injured: Social Security Number: Date of Accident: Where did Accident Happen? How did Accident Happen? Describe Injury(s): Name and es of Hospitals, Doctors or other Health Care Providers that have Treated Injured Person: Name and es of Persons or Entities Responsible for Accident:
4 Name of Attorney for Person Injured: : If Accident involved an automobile or motorcycle, list the participant s auto insurance company: If Accident involved an automobile or motorcycle, list the other Party s auto insurance company: If Accident occurred in or around the Participant s home or property, list the Participant s homeowner insurance company. If Accident occurred in or around the other Party s home or property, list the other Party s homeowner insurance company. If available, attach copy of the Accident Report sent to Insurer. Were Police Notified? Yes No Were charges lodged against you? Yes No Against other Party? Yes No, not at the time
5 Was the Accident Employment Related? If yes, describe the circumstances of the accident as they related to the injured person s employment: Has a Workers Compensation Claim been filed? If yes, State: Name and of Employer: Name and of Employer s Workers Compensation Carrier: Carrier s Claim No.: Name of Carrier s Adjuster: Docket No. of Compensation Proceeding (if applicable): Name and of Workers Compensation Attorney for Injured Employee: Telephone No.: I hereby certify that the above information is true and correct. (Signature) Date:
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