Dear Parent or Guardian:

In order to receive benefits based on the School’s Student Accident Policy, all medical bills must be first submitted to your own health insurance carrier providing your primary medical coverage. Student Accident Insurance is intended to be a supplemental coverage to your primary carrier’s coverage, therefore, benefits will not be paid for medical expenses covered by your own health insurance.

Please note that Commercial Travelers Mutual Insurance Company is the claims administrator not the liability carrier.

Student Accident Insurance is administered by Commercial Travelers Mutual Insurance Company. In order to claim expenses not covered by your primary health insurance, the following steps must be followed:

• School Official completes Part A of the Student Accident Claim Form.

• Parent/Guardian completes Part B of the Student Accident Claim Form. Please note that the Student Accident Claim Form must be fully completed. Student Accident Claim Forms not fully completed can cause the Claim Representative to return the Claim Form and cause processing delays.

• Please submit the completed Student Accident Claim Form within 90 days from the date of accident.

• Submitting the appropriate documentation is essential for timely adjudication of your claim expenses.

• Please note: If you are receiving treatment from a provider (primary care physician), please request a CMS 1500 (see attached example). If you are receiving treatment from a hospital, please request a UB04

• Please submit any Notice of Payment or Rejection (explanation of benefits—EOB) forms from your primary health insurance carrier. Any itemized billing statements submitted must include a diagnosis code and procedure code.

• Please notify all physicians, hospitals and any other healthcare providers that have or will be treating your child and provide them the insurance information about the school’s accident insurance carrier. Please ask the providers to bill the claims administrator as secondary insurance at the following address:

  • Commercial Travelers Mutual Insurance Company
    Attn: K–12 Claim Administration
    70 Genesee Street
    Utica NY 13502
    Fax No. 315-797-0195

• Should you have any questions or concerns regarding your coverage or claim, please call the claims administrator,
  Commercial Travelers Mutual Insurance Company at 1-800-756-3702.