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Fillable STUDENT CLAIM FORM * DENOTES REQUIRED INFORMATION - chiltonisd

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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...
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