Filing a Claim

How to File a Medical Claim (For Special Risk, Sports, Campers, Youth Groups, and Participant Accident Insurance Policies)

Attached below is a claim form for your accident policy. Please forward claims and questions to the following address:

90 Degree Benefits
PO Box 6540
Harrisburg, PA 17112

Step 1:  Submit a completed Notice of Claim (claim form) via either mail or facsimile.

The Participating Organization (not the Parent, Claimant or Agent) should:

  • Fully answer each item in Part I, The Participating Organization Report.
  • Read the fraud warning statement on page 3 and sign the form where indicated in Part I.

The Parent/Guardian or Adult Claimant should:

  • Fully answer each item in Part II, Other Insurance Statement.
  • Review Part III, Authorizations.
  • Read the fraud warning statement on page 3 and sign where indicated on the bottom of the Claim Form.

Step 2:  Submit itemized medical bills for payment consideration to our office. If other insurance exists, include the other insurance company’s corresponding Explanation of Benefits (EOBs).

Helpful Information for Submitting Claims and Expediting Payment

  • A fully completed Claim Form is required for each accident/injury. Claims submitted with incomplete information will not be paid pending receipt of the missing information.
  • The acceptance of a claim form by an Insurance company is not an admission of coverage
  • Providers may wish to bill us directly. If they do, please ensure a completed claim form has first been submitted to our office.
  • In order to ensure we receive complete claim information, we suggest providers submit standardized billing statements (called “UB-04” for hospital charges and/or a “CMS-1500” for Physician Charges).
  • Unless proof of payment is submitted with the medical bill (a copy of the check, a medical bill that indicates the claimant has made all or partial payment or zero balance information) claim payment is generally sent directly to the medical providers.

Claim Form

A claim form, prefilled with the school district's name and policy number can be accessed by clicking the link below.

Insurance Claim Form