Hospital Indemnity Claim Form

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime, and subjects such person to criminal and civil penalties. By signing below, you agree under penalties of perjury that the information in this statement is complete and true to the best of your knowledge.

Please refer to the “Fraud Warning Notices” insert for your state.

Required Documents

Please attach the following documents using the file uploader below.

Failure to attach the necessary documents will cause your claim to be denied.

1. Explanation of Benefits (EOB) provided by the insurer for your Comprehensive Major Medical Plan, aka your Health Insurance

2. Itemized Bill

Protecting Your Information

AME Trust (herein referred to as “we,” “us,” “our”) maintains physical, electronic and procedural safeguards to protect your nonpublic personal information.

Collecting Information

We collect information about you in order to conduct business. Such uses are: to process requests for insurance products, to provide customer service, to process claims, to fulfill legal and egulatory requirements and for other lawful purposes. We collect this information from you, as well as from other sources. We restrict access to your information to those working on our behalf who have a need to know it in order for us to provide products and services to you. We require them to secure the information and keep it confide tial.

Information we collect may include all the information you share with us, including for example, your:

• name
• address
• telephone number
• date of birth
• social security number
• employer name and income
• inancial a count numbers
• medical information
• beneficiar data
• and other information you share with us

We may also collect data we receive from other souces, allowed by law, which may include:

• medical information
• consumer report information in accordance with the Fair Credit Reporting Act
• participant information from organizations that purchase products or services from us for the benefit of their members or employes, such as group insurance
• information to assist us in complying with state and federal laws

Sharing Information

We do not share information about our customers or former customers with anyone, except as permitted or required by law.

We may share information with third parties without your authorization as permitted by law. Such information is used on our behalf by these third parties to:

• process or service your insurance transactions with us
• perform underwriting, administrative, account maintenance and claims functions
• provide customer service or reinsurance coverage prevent fraud

• perform other business functions on our behalf

We may also share your information with:

• a consumer reporting agency in accordance with the Fair Credit Reporting Act
• a third party to comply with federal, state or local laws, subpoenas, or summonses
• regulators
• or as otherwise permitted or required by law

Third parties receiving information from us are required to: keep it confidential and to comply with all applicable federal and state privacy laws.

Sharing Information

You have the right to request access to all the information we have on you. You must make your request in writing to the address below.

Amendments to Your Information

You have the right to request an amendment, correction or deletion of information which we hold about you which you believe may be inaccurate. We are not obligated to make updates to your data based on your request. You must make the request in writing and state the reasons you are requesting the change. Write us at the address below.

If you have questions about this notice or would like more information about our privacy policies, please write us at:

AME Trust

[address]