Fillable STUDENT CLAIM FORM * DENOTES REQUIRED INFORMATION - 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...
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