ࡱ> z|y bjbj ]>jjq ul,,,,,,,$PPL(4P;`hxxxx .  ,,,,5J,@3@:$!= A?:,! !!:F%,,xx4{;F%F%F%! ,x,x,F%!,F%&F%l'*,,+x\ PJۘP<&# ++;0;+@F%@+F%PP,,,,CIVIL AIR PATROL DEATH BENEFIT/MEDICAL EXPENSE CLAIM FORM (SENIOR MEMBERS AND CADETS) Name of Injured or Deceased Member  FORMTEXT       Senior  FORMCHECKBOX  Cadet  FORMCHECKBOX  Last First Middle Initial CAP Charter No:  FORMTEXT       CAPID:  FORMTEXT       Date of Birth  FORMTEXT       Day Month Year Address:  FORMTEXT       Street City State Zip PART 1: ACCIDENT INFORMATION When and Where did this accident occur:  FORMTEXT        FORMTEXT        FORMTEXT    Date City State Give a brief description of the accident:  FORMTEXT        FORMTEXT        FORMTEXT       Was the injured person involved in an official activity?  FORMTEXT       Person who authorized CAP Activity: Name and Grade:  FORMTEXT       Position:  FORMTEXT       Address:  FORMTEXT       Phone No.  FORMTEXT       Street City State NOTE: ATTACH CAP FORM 78 IF AVAILABLE. ATTACH DEATH CERTIFICATE IF APPLICABLE. PART II-. FAMILY INFORMATION (Do Not Complete in Death Cases) Name of Employer, (Parents of Cadets):  FORMTEXT       Name of Employer, (Parents of Cadets):  FORMTEXT       PART III: OTHER INSURANCE INFORMATION (Do Not Complete in Death Cases) Is there medical reimbursement coverage available from any insurance company or program e.g. Champus: Yes FORMTEXT   No FORMTEXT   Name of Insurance Company:  FORMTEXT       Policy No:  FORMTEXT       Address:  FORMTEXT        FORMTEXT       Street City State Zip Phone No. Agent Name & Address:  FORMTEXT       Agent Telephone Number:  FORMTEXT       Have you filed a claim with another insurance company?  FORMTEXT       Are you covered by Workmen's Compensation from this accident?  FORMTEXT       PART IV: REIMBURSEMENT INFORMATION (Do Not Complete in Death Cases) Total amount of medical expenses incurred for the accident (attach bills)  FORMTEXT       Reimbursement from other insurance (attach claim information & copy of payment)  FORMTEXT       Indicate amount of other insurance deductible  FORMTEXT       Indicate amount of other insurance co-insurance (attach copy of payment)  FORMTEXT       Indicate to whom CAP benefit check should be payable:  FORMTEXT       Will there be additional amounts claimed from CAP? Yes  FORMTEXT       No  FORMTEXT       IMPORTANT: To avoid delay, please sign Authorization below: I hereby authorize any Insurance Company, Organization, Employer, Hospital, Physician, Surgeon or Pharmacist to release any information requested with respect to this claim and the attached bills. I certify that the information furnished in this report is true and correct to the best of my knowledge. Date  FORMTEXT       Signed Member: Charter No:  FORMTEXT       CAPID:  FORMTEXT       Parent/Guardian/Next of kin:  FORMTEXT       (if member is a minor) Address:  FORMTEXT       Street City State Zip Telephone No:  FORMTEXT       Home  FORMTEXT       Work ALL BILLS TO BE CONSIDERED FOR REIMBURSEMENT MUST BE ATTACHED TO THIS STATEMENT. SEND TO: NHQ CAP/GC BLDG 714, 105 S. HANSELL ST. MAXWELL AFB AL 36112-6332 NOTE: Benefits are payable only for accidental injuries or deaths incurred on official CAP activities. Medical benefits are excess to existing coverage and will be made to the member or family only. 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Q-"2 OPR/ROUTING: GC6+2266-6552- 2 ) '-@Times New Romanww0-a2 O9CIVIL AIR PATROL DEATH BENEFIT/MEDICAL EXPENSE CLAIM FORM< < 7< <3<7<A7<7<7A87<73 7P7< <<77<37<.7<7< P3A<P- 2  %-42 'A(SENIOR MEMBERS AND CADETS)q.7< A<P7P87<.<<<<<<77.- 2 (  % 2  %-@2 #Name of Injured or Deceased Member <%?%*))%**<%%%% %*J%?*%@ Arialw@ Hww0- 2  2  . 2  2  . 2 5 2 5 . 2 c 2 c . 2  2  .- 2  - !=-2   Senior .%)*'-- ?-- ' - 2   Cadet e7%*%'-- ?e-- ' -  2 n %' 2 L !2 LLast 2%  2 L K2 L First e.  2 L  "2 L Middle Initial J**%)% 2 Lz %'-#2 CAP Charter No: 7;/7)%%<*- 2  2  . 2 F 2 F . 2 t 2 t . 2  2  . 2  2  .- 2  O- !5-2 MCAPID: e7;/<- 2 r 2 r . 2  2  . 2  2  . 2  2  . 2 * 2 * .- 2 X A- !'r- 2  Date of Birth <%%*8)- 2 e 2 e . 2  2  . 2  2  . 2  2  . 2  2  .- 2 K g- !Me- 2  %' 2  2 [Dayt<%( 2  ~2 bMonthJ*)) 2 ? 2 Year<%% 2 { %'-2  Address: ;**% - 2  2  . 2 , 2 , . 2 Z 2 Z . 2  2  . 2  2  .- 2  - !- 2  %' 2  2 Street.%% 2  2 2 City7( 2   2 jState.%% 2  92 IZipt2* 2  %'-52 PART 1: ACCIDENT INFORMATION3<<7*<<< <7<7 <3A<P<7 A<- 2 O %' 2  %'-G2 ](When and Where did this accident occur: O)%)%)*O)%%**) %%%*%)*%%)- 2 ]8 2 ]8 . 2 ]f 2 ]f . 2 ] 2 ] . 2 ] 2 ] . 2 ] 2 ] .- 2 ] - 2 ]  2 ]  . 2 ]  2 ]  . 2 ]:  2 ]:  . 2 ]h  2 ]h  . 2 ]  2 ]  .- 2 ]  - 2 ] 2 ] . 2 ] 2 ] .- 2 ] - !z 8- 2 ] %' 2  2 SDate<%% 2  2  City7( 2 k   2 . X2 State.%% 2 , %'--I2 !)Give a brief description of the accident:<)%%*%*% %**)*)%%%%*%)- 2 !  2 ! 2 ! . 2 !0 2 !0 . 2 !^ 2 !^ . 2 ! 2 ! . 2 ! 2 ! .- 2 ! - ! t- 2 ! %' 2  %'- 2  2  . 2  2  . 2  2  . 2 L 2 L . 2 z 2 z .- 2  - !7- 2  %' 2 D %'- 2  2  . 2  2  . 2  2  . 2 L 2 L . 2 z 2 z .- 2  - !- 2  %' 2   %'--_2 g 8Was the injured person involved in an official activity?O% )%))%**% *)))*)%*)%)*%%%%)(&- 2 g   2 g  2 g  . 2 g .  2 g .  . 2 g \  2 g \  . 2 g  2 g  . 2 g  2 g  .- 2 g  - ! - 2 g  %' 2  %'@2 + #Person who authorized CAP Activity:/% *):)*%))*%%*7;/;%)( 2 +  %' 2  %'--2 Name an<%?%%)2 d Grade:*<%*%- 2   2 # 2 # . 2 Q 2 Q . 2  2  . 2  2  . 2  2  .- 2   2  - !B -2 Position: /* *)- 2 0  2 0  . 2 ^  2 ^  . 2  2  . 2  2  . 2  2  . 2  - !B 0 -- 2  %' 2 Q  %'--2 Address:;**%  2  A- 2 * 2 * . 2 X 2 X . 2  2  . 2  2  . 2  2  .- 2  - ! *-2  Phone No. /)*)%<*- 2 c   2 z  2 z  . 2  2  . 2  2  . 2  2  . 2 2 2 2 .- 2 ` Z- !W c - 2  %' 2   2  Street.%% 2  T v2  City7( 2  W  2  State.%% 2   %'@Times New Romanww0-2 /ONOTE: ATTACH CAP FORM 78 IF AVAILABLE. ATTACH DEATH CERTIFICATE IF APPLICABLE.7<.33..37<7333<3E**3333.33.33..37<<33.<733.373.33333.733.3- 2  0%'-2 PART II3<<7 2 -042 . FAMILY INFORMATION (Do NN3<P 7< <3A<P<7 A<<*<42 ot Complete in Death Cases)N*<*C.%%.<%*.<* % - 2  0%'--&2 mName of Employer, <%?%*3?**(%-)2 mf(Parents of Cadets):3* %* *7**% - 2 m  0 2 m$ 2 m$ 0. 2 mR 2 mR 0. 2 m 2 m 0. 2 m 2 m 0. 2 m 2 m 0.- 2 m  0 - !  - 2 m %'--&2 5Name of Employer, <%?%*3?**(%-)2 5f(Parents of Cadets):3* %* *7**% - 2 5   2 5$ 2 5$ . 2 5R 2 5R . 2 5 2 5 . 2 5 2 5 . 2 5 2 5 .- 2 5  - !  - 2 5 %'-t2 FPART III: OTHER INSURANCE INFORMATION (Do Not Complete in Death Cases)3<<7 A7A7< <.<<<<<7 <3A<P<7 A<<*<*<*C.%%.<%*.<* % - 2   %'C2 _%Is there medical reimbursement covera )%%?%*%%%?*) %?%)%*)%%^2 _7ge available from any insurance company or program e.g.?)%%)%%*%*?%)() )%)%%%*?*%)(***)%?%) 2 _E %' 2  %'-2 # Champus: Yes7)%?*) <% - 2 # 2 # .- 2 # '- !Uv- 2 #No<*- 2 #a 2 #a o.- 2 # o - !7va- 2 # %' 2  %'---22 Name of Insurance Company:<%?%*) )%)%%7*?*%)(- 2   2  2  . 2  2  . 2  2  . 2 E 2 E . 2 s 2 s .- 2  - !:- 2 ~  :2  Policy No:/*%(<*- 2    2 5  2 5  . 2 c  2 c  . 2   2   . 2   2   . 2   2   .- 2  - !: - 2  %' 2 I %'-2  Address: :;**% - 2  2  . 2 , 2 , . 2 Z 2 Z . 2  2  . 2  2  .- 2  - !| - 2 z  ,- 2  2  . 2  2  . 2  2  . 2 0 2 0 . 2 ^ 2 ^ .- 2  S- !9- 2  %' 2  R2 Street.%% 2  2 City7( 2 2  ;2 m State.%% 2   2  Zipt2* 2 2  t2  Phone No.:/)*)%<* 2  %'-,2 Agent Name & Address: ;)%)<%?%@;**% - 2   2   . 2 9 2 9 . 2 g 2 g . 2  2  . 2  2  .- 2  - ! 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