Accident or Injury Claim

You may have received a letter from Aetna regarding a claim that appears to be accident related.  The reason you would have received this is because there may be another person or insurance company that may be responsible to pay that claim.  This is referred to as “Subrogation.”

The Costco Plan is designed this way to ensure that Costco does not pay for claims that could be another party’s responsibility.  This is one way that Costco is able to provide a high level of benefits at a low cost to you.  

Therefore, it is important for you to identify if your claim is accident-related or not as soon as possible, so that Aetna can process your claim timely and appropriately.

We’ve tried to make this easy by including the short form below.  Please take time to submit your response today, so that we can complete processing your claim.  Thank you.



Accident Inquiry Form

Fields marked with an (*) are required.
Employee Contact Information


















Yes No




Yes No
Details of Injury



Home School Work Auto Other




?
Yes No

Yes No

Yes No
At Fault For injuries or conditions caused by another party, list the party liable for the above condition and list his/her insurance.



Patient's Insurance Information For injuries or conditions which will be settled under the provisions of your own automobile medical, Personal Injury Protection (PIP), uninsured or underinsured motorist coverage (UIM), homeowners or other similar type coverage, complete the following:



Settlement Information
Yes No Unknown


Yes No




:
Yes No


Yes No


Yes No


Yes No

Attorney Information

If an attorney is representing you in this matter, please provide us with the following information.



Occupation

For injuries or conditions that resulted from performing work required by your job, please provide us with the following employer information:


Yes No


Yes No

:
Yes No


Yes No




If Labor & Industries denied your claim we may contact you to request a faxed copy of the form so your claim may be reconsidered for processing by Aetna.

Reimbursement Agreement

Please complete and return the Reimbursement Agreement. We will need the completed and signed form before we can issue any payments on your claims.

You may fax the form to 1-859-455-8650, or mail to:

  • Aetna
  • PO Box 981106
  • El Paso, TX 79998-1106

For your protection, California law requires notice of the following: Any person who knowingly and with intent to defraud or deceive any insurance company files a statement of claim containing any materially false, incomplete or misleading information is guilty of a crime and may be subject to fines, confinement in a state prison, and substantial civil penalties. Many other states have similar laws. Attention Colorado Residents: An insurer or agent who knowingly provides false or misleading information to defraud a claimant regarding insurance proceeds must be reported to the Insurance Division.

My initials below indicate the information provided is correct.