UPS Enrollment Form

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Proof of Loss Form

Your intake fee covers insurance during your Community Service in case of injury. Please complete the form below to enroll in the insurance coverage.
Hawley & Associates LLC

Blanket Accident Medical-Excess Coverage Only

Volunteer Insurance Services
Name of Volunteer: *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date
Gender of volunteer*
Age of volunteer*
Occupation*
I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release any information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information concerning the patient, to any insurance company, the Plan Administrator or their employees and authorized agents for the purpose of validating and determining benefits payable. This data may be extracted for use in audit or statistical purposes. I understand that I or my authorized representative will receive a copy of this authorization upon request. This authorization or a copy of the original shall be valid for the duration of the claim.

Any person who knowingly and with intent to defraud any insurance company or other person files a statement containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.
Signature of Volunteer*

Clear
Date*

MonthDayYear
Date

UPS Enrollment Form

Client Information

Emergency Contact Information

Case Related Information

Proof of Loss Form

Recovery Resources Resilience Survey