CHILTONISD
School District: City and State: STUDENT CLAIM FORM 1. Please fully complete this form 2. Attach itemized bills 3. Mail to HSR E-mail : K12claims@hsri.com P.O. Box 117558 Carrollton, Texas 75011-7558 Phone: (972) 512-5600 Fax: (972) 512-5818 Toll Free (866) 409-5734 School Name: Policy Number: * DENOTES REQUIRED INFORMATION PART I POLICYHOLDER'S REPORT 1.* Claimant's Name (injured/ill person) 2.* Social Security Number 3.* Gender M F 4.* Date of Birth 5. E-Mail 6.* Address of Injured Person 8 MoreThis claim form should be fully completed and submitted within 90 days from the date of injury. ... Only one claim form for each accident needs to be submitted. 3. Less
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