- The claim form must be completed in full and signed by the appropriate school
official. Please be sure to detail accident information, include part of the body
injured, how the injury occurred and the particular sport. A separate claim form
(Part1A) is required for each injury.
- Please complete Part1B of our claim form in full (Parent/Insured Information). If
there is no evidence of other valid and collectible insurance, we must still receive
the completed form to process the claim.
- If the student does not have contact with a parent, please indicate this in Part1B.
Students that are independent of their parents, please note this.
- Please sign and date the portion of the claim form indicating “Medical information authorization/Assignment of benefits”.
For more information, click the “Claim Filing Instructions” link below.
You may download the claim form below.
BMI Benefits, LLC.
PO Box 511
76 Main Street
Matawan, NJ 07747