Insurance Information and Claim Form
Claim Procedure
- Complete and sign the claim form.
- The medical coverage has a $1,000 deductible. You should pay the first $1,000 at the time of treatment, depending upon your medical insurance.
- Send the claim form and medical bills to the address listed below.
- Claim must be filed within 30 days of injury.
IF THE CLAIM FORM IS NOT COMPLETELY FILLED OUT, IT WILL BE RETURNED FOR COMPLETION BEFORE BILLS CAN BE PAID.
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Arraigned by:
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Western Specialty Insurors
888-866-3550
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Claims Office:
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Health Special Risk, Inc
HSR Plaza
4100 Medical Parkway
Carrollton, TX 75007
877-534-7669 (fax) 972-512-5820
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Click on link for claim form:
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https://prca.hsri.com/incident-reports
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