Accident or Injury Claim

Have you recently received a letter from Aetna asking if one of your healthcare claims is the result of an accident? The reason you received the letter is because there may be another person or insurance company who is financially responsible to pay some or all of the costs of that claim.  This is referred to as “Subrogation.”

One of the ways Costco is able to provide a high level of benefits at a low cost to employees and their families is to make sure the plan only pays for expenses that are not the responsibility of another party or insurance policy – like auto insurance.

To avoid delays in claim payment it’s important for you to respond to the letter you received, even if the claim is not the result of an accident.  If there is no other party responsible Aetna can quickly and appropriately process your claim. While we wait for you to respond your claims will be pended for payment.

Responding is easy – you can follow the instructions on the letter or complete the on-line form below. No matter which way you respond – letter, phone call or on-line – please remember omitting facts or willfully giving wrong or misleading information is considered “Falsification of Company Records” and could result in disciplinary action up to and including termination of employment.  In addition there may be underlying state laws that impose fines, civil penalties and possible confinement.

If you have any questions completing this inquiry please call Aetna Member Services at 1-800-814-3543.



Accident Inquiry Form

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
















Patient information is same as Employee














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 and Authorization Form

IMPORTANT: Please complete and return BOTH the Reimbursement Agreement and Authorization form. 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
Reimbursement Agreement and Authorization Form

IMPORTANT: Please complete and return BOTH the Reimbursement Agreement and Authorization form. 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
Reimbursement Agreement and Authorization Form

IMPORTANT: Please complete and return BOTH the Reimbursement Agreement and Authorization form. 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
Reimbursement Agreement

IMPORTANT: 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
Reimbursement Agreement

IMPORTANT: 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
Reimbursement Agreement

IMPORTANT: 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.