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Safety National » Request For Reimbursement – Specific claim (Expenses Prorated)

Request For Reimbursement – Specific claim (Expenses Prorated)

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Reimbursement of Indemnity, Medical & Expense Payments Total Amount

Indemnity Paid to Date:
Medical Paid to Date:
Total Gross Indemnity and Medical Paid to Date:
Minus SIF/Subrogation/Other Recoveries:
Minus Penalties/Interest/Other Exclusions:
Total Net Amount Paid to Date:
(1)
Minus Self-Insured Retention:
Amount Paid in Excess of Self-Insured Retention:
(2)
Minus Prior Safety Reimbursements:
Total Indemnity and Medical Expenses Requested:
(a)

Reimbursement of Allocated Expenses

Final Reimbursement
Allocated expenses, which include legal fees, are not reimbursed in the same manner as indemnity and medical payments. Per the contract, expenses are reimbursed on a pro rata basis at the conclusion of the claim.

Safety National’s share is computed using the following formula:

Total Amount Requested = (a)Total Indemnity and Medical Expenses Requested + (b)Safety National's share

  • Attach payment summary and detail printout by reserve category to process reimbursement.
  • Attach approved settlement documents if request covers settlement funds (one time only).
Drop files here or
Max. file size: 256 MB, Max. files: 10.

    Sworn Statement in Proof of Loss

    The undersigned, as the designated representative for the above Named Insured, states that the above figures are true and correct. Any statements attached hereto are made part of this instrument.

    Name
    Address*

    Bank Information

    Reimbursement Method
    Bank Address*
    Company Address*
    This is the address your check will be sent to.