Claim Form

LEGAL NOTICE: Any person who knowingly, and with the intent to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

After completing this form you may click the "SUBMIT" button at the bottom of the page and send it electronically OR click on the "PRINT" button on your browser to print it out and mail it, along with any other required documentation to:

Macori Administration
PO Box 2508
Spring, TX 77383-2508

Please complete in detail to ensure prompt handling.

E-mail address at which you can be contacted:
Policy Number:

Insured Information:

Insured's Name:


Insured's ID Number:                                   
Insured's SSN:

Birth Date:
Telephone No.

Present Address:
(No. & Street )



Home Address:
(No. & Street )





If claim for dependent:
Dependent's Name:
Relationship to Insured:         Birth Date:


Are you covered by any other hospital and/or medical plan?    Yes     No

If YES, please complete this section:
Please Check one: Group Individual Other
Name and policy number of Insurance Company:

(Name of Insured)



(I.D. #)
Have you filed a claim with the above company?
No Yes I have no other insurance If yes, send copies of Explanation of Benefits showing benefits paid and/or denied to company at the address above.
Name and Address of Employer of
Insured, if employed:
Spouse, if Insured is married (domestic partnership):


Details of Accident or Sickness:
Date of Accident or Sickness: (mm-dd-yyyy)
Date of First Treatment: (mm-dd-yyyy)
Nature of Sickness or Injury:
If injury, describe how/when/where accident occurred:
Indicate if work related: No Yes
If injured, in play or practice of sport, indicate which sport and type of activity:
Club Intercollegiate Intramural Other
Does the team have injury coverage?
No Yes
Have you previously been troubled with this condition?
No Yes, on: (mm-dd-yyyy)
Names of all other physicians consulted:
Physicians Address:
(No. & Street )



Yes, at  
Health Center Referral?
(if required)
Yes. Submit a copy by fax, e-mail or postal mail (not required if your student health center submits referrals on your behalf).
No. Please explain:




Payment will be paid to the providers of service (Doctor and others), unless a paid receipt or statement accompanies the bill at the time the claim is submitted.

In submitting this form,

  • I certify that the above information given by me in support of this claim is true and correct.
  • To any medical care provider, medical care facility, insurer, government-sponsored health plan or employer:
    I permit (while my claim is pending) the release of any medical information about me to the Company and its representatives including reinsuring companies and other persons or groups performing business or legal services to my claim. This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past. The Company will use this information to find out if my claim is eligible. A copy of this authorization (one of which would be given to me by the Company upon my request) will be valid as this one.

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