Special Risk Division Claim Form

Download Claim Form

How to Submit a Claim

To submit a claim, download this form. Complete all sections, then send the form and all related itemized medical bills to us:

Via Mail: AIL SRD
PO Box 50158
Indianapolis IN 46250

Via Email: claimsSRD@ailife.com

Via Fax: 317-849-2793

We process claims within 30 days of submission.

To help expedite the process, please follow these steps:

Submit your claim report form to us as soon as possible after the incident.

Even if you haven’t received bills yet, sending us a claim form allows us to review the claim and contact you if we need additional information.

Fill out the entire claim report.

Make sure all six sections are completed. The form MUST be signed by a camp director, chaperone, or group leader of the policyholder who is UNRELATED TO THE PATIENT.

Send medical statements (itemized bills) to us as soon as possible.

We need the “itemized bill,” which shows diagnosis and procedure codes. You may need to contact the medical provider to get this detailed bill. Don’t rely on the medical facility to forward information to us.

Send us all information needed for reimbursement of paid bills.

If you or the patient have already paid expenses, keep copies of the receipts. Send us the following information:

  • Name and address of person to be reimbursed.
  • Proof of payment – a paid receipt, credit card receipt, or cancelled check
  • Prescriptions: Receipt showing patient name, Rx number, name of prescription, and price
  • Treatment/Appointments: Itemized bill showing diagnosis and procedure codes as well as billed amount
  • Include an Explanation of Benefits if the claim has been paid by a personal insurance provider.

We know that the aftermath of an accident can be a stressful and confusing time. If you have questions that are not answered in the Frequently Asked Questions below, please don’t hesitate to contact us.


Claims FAQ

Claim forms or itemized bills may be mailed, faxed to 317-849-2793 or emailed to ClaimsSRD@ailife.com. Mailing address is:

AIL Claims
P.O. Box 50158
Indianapolis, IN 46250

AIL Special Risk Division will reimburse for eligible medical expenses directly related to the initial injury up to the policy limits. There are some reasonable limitations. For example, over the counter medications, supplies, durable medical equipment, lost wages, and fees are not eligible for reimbursement. Receipts/itemized statements are required for all submitted charges. AIL Special Risk Division will contact the insured and policyholder when policy benefits have been exhausted.

Any licensed medical professional or facility may be used. The company suggests clinics, doctors’ offices, and other urgent care facilities for non life threatening injuries. Hospital emergency rooms may be utilized when no other options are available. Chiropractic services require a referral from a family doctor or urgent care facility. There are some limitations and exclusions for chiropractic services.

Provide a claim form to the company within 20 days of treatment, but no later than 90 days after the covered event ends. Prompt submission of a claim form facilitates better communication between the policyholder, patient and medical providers. Itemized statements must be submitted within one year of the date of injury or illness. Eligible medical expenses must be submitted to AIL Special Risk Division within one year of the treatment date.

Itemized bills and paid receipts are submitted with the name, address, phone number, and email for the individual to be reimbursed. If no instructions are provided, AIL will reimburse the medical provider.