Garrison Property and Casualty Insurance

Company CLAIM INSTRUCTIONS

ALEX KENNEDY
13620 BASS TRL
GRASS VALLEY CA 95945

Documentation Needed for Your Claim

November 7, 2019

Dear Alex Kennedy,

This letter acknowledges receipt of the following claim:

USAA policyholder: Steven T Frei

Claim number: 032113541-026
Date of loss: July 25, 2019
Loss location: Marysville, CALIFORNIA
Patient: Alex Kennedy

To expedite your Bodily Injury claim, either you or an appropriate party should complete and return the enclosed forms:

· Authorization for Disclosure of Medical Information to USAA

· Wage and Salary Verification
· List of Providers/Employers

How to Contact Us
Please send any correspondence or questions to us using one of the following options and include the claim number
above on each page mailed or faxed:

Address: Auto Injury Solutions

Attn: USAA Medical Mail Department
P.O. Box 26001
Daphne, AL 36526

Fax: 866-828-2330

Phone: 1-210-531-8722 ext.48986

Include my full name and the claim number 032113541-026 on all correspondence. If I need additional information, I’ll
request it from the appropriate party.

032113541 - 026 - 4503 - 03 54386-0419

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According to CALIFORNIA statute of limitations, you must file and settle bodily injury claims within 2 years from the date
of the accident. You must settle or protect your legal rights before the statute expires.

Sincerely,

Cody Lambson
Injury Unit
Garrison Property and Casualty Insurance Company

Garrison Property and Casualty Insurance Company, a subsidiary of USAA Casualty Insurance Company, is authorized to use the USAA logo, a
registered trademark of United Services Automobile Association.

Enclosed: Medical Authorization - MA059

Wage and Salary Verification - MAP010F
List of Providers/Employers - MAP044F

032113541 - 026 - 4503 - 03 54386-0419

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 Garrison Property and Casualty Insurance
Company
AUTHORIZATION FOR
DISCLOSURE OF MEDICAL
INFORMATION TO USAA

Member Name Claim Number Date of Loss

Steven T Frei 032113541 - 026 07/25/2019

We are not HIPAA covered entities. Your disclosure of information to us is not subject to
the Minimum Necessary standard.

Patient: Alex Kennedy

I HEREBY GRANT PERMISSION TO, AND AUTHORIZE THE USE OR DISCLOSURE OF,
THE ABOVE NAMED INDIVIDUAL'S RECORDS.

I authorize the following persons and organizations (a) any licensed physician, surgeon,
or dentist; (b) any psychiatrist or psychologist; (c) any other medical practitioner or
nurse; (d) any hospital, clinic, health care facility or rehabilitation/ convalescent/
custodial facility; (e) ambulance owner; (f) any insurance company (the "Provider") to
provide information (as defined below) to GARRISON and/or their retrieval service
ABI/VIP.

I, the Undersigned, as the patient, or in my capacity as personal representative of the

patient, Alex Kennedy understand the information obtained by this Authorization will be
used by GARRISON and its authorized representatives, performing business or legal
services, its affiliated insurance companies, and its authorized representatives,
performing business or legal services for the purpose of verification, evaluation, and
negotiation of any claim for benefits or services, arising from the above-identified date of
loss, and any other pertinent claim handling or legal uses in connection to such claims.

For purposes of this Authorization, "Information" means all records or knowledge

concerning the patient's health, any injuries, medical history, mental and physical
conditions, before and after the date of this Authorization, regardless of the time of
occurrence. The term "records" includes, but is not limited to, written or graphic
documentation, including notes, billing records or statements, sound recordings,
computer records of health care services, and diagnostic documentation, such as x-rays,
lab test results, and other test results such as blood alcohol level and drug use. In
addition to medical records developed by the Provider described above, this

MA059 51063-1217
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Authorization also includes any medical records received by the Provider from other
providers.

This Authorization shall be in force and effect until all claims arising from the above-
identified date of loss are concluded, but no more than 24 months, at which time this
Authorization to disclose this information expires.

MA059 51063-1217
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I also understand and agree to the following:

· Although this Authorization is voluntary, GARRISON reserves the right to

discontinue processing any claim if I refuse to grant this Authorization, and such
refusal may be in breach of a policy condition if GARRISON reasonably needs this
Authorization to adequately investigate any claim.

· That the information released pursuant to this Authorization may be redisclosed by

USAA and may no longer be protected by federal privacy regulations.

· That I may receive a copy of this Authorization, and I have the right to revoke this
Authorization, in writing, at any time. I may request a copy or revoke the
Authorization by sending such written request to

Auto Injury Solutions, Attn: USAA Medical Mail Dept at

P.O. Box 26001, Daphne, AL 36526

· That a revocation is not effective: (i) until receipt by GARRISON, and (ii) to the
extent that GARRISON has relied on the use or disclosure of the information.

· That: (1) this Authorization overrides any existing agreement to restrict information
pursuant to 45 CFR 164.502(b)(2)(ii), (2) a copy of this Authorization is as valid as
an original, and (3) I have read and understand this Authorization.

CALIFORNIA Statutes, Section 1871.2(a) states: "For your protection California law requires the following to appear on this form. Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."

THIS IS NOT A RELEASE OF CLAIM FOR DAMAGES.

Signature of Patient or Personal Representative Date

MA059 51063-1217
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Patient's Date of Birth / Social Security Number

Description of Personal Representative's Authority

(Reminder: Please return this entire form, including the signature page.)

MA059 51063-1217
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 Garrison Property and Casualty Insurance
Company
WAGE AND SALARY
VERIFICATION

Member Name Claim Number Date of Loss

Steven T Frei 032113541 - 026 07/25/2019

Complete This Form Only If You Are Claiming Lost Income

TO WHOM IT MAY CONCERN
As a result of injuries sustained in a vehicle accident on the date indicated, the person named below has applied for benefits under
Bodily Injury It is our understanding that this person is or was employed by your company. To assist us
in determining benefits that may be due, please provide us with this necessary employment information.

Employee's Name
Alex Kennedy
Address
13620 BASS TRL, GRASS VALLEY CA 95945,
Occupation Job description

Length of Service Dates of Employment Gross Earnings During 52-Week Period Prior To Accident
From: Through: $

Wage or Salary As of Date of Accident Dates Absent As a Result of Accident

$ ¨ per Hour From: Through:

$ ¨ per Week From: Through:

$ ¨ per Month From: Through:

$ ¨ Commission From: Through:

Total Number of Hours

Lost:

Usual Number of Usual Number of

Hours Worked per Day: Hours Worked per Week:

Disability Began: Returned To Work:

Total Hours Missed: Total Days Missed:

Was employee paid during this absence? ¨ Yes ¨ No If "yes," amount paid: $

Was payment a result of sick leave used? ¨ Yes ¨ No

When employee returned to work, was employee able to perform all required duties? ¨ Yes ¨ No
If no, please describe the limitations

MAP010 51065-1217
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Is employee entitled to receive benefits under a wage ¨ Yes If 'yes,' Amount per Week
Or salary continuation plan? ¨ No Paid or Available: $ per Month

Has employee received, is he/she receiving, or is he/she entitled to receive benefits under workers' compensation as a result of this accident?
¨ Yes ¨ No ¨ Undetermined
If "yes," Give Name, Address, and Telephone Number of Compensation Carrier or Claim Representative:

Name: Telephone Number:

Address:

CALIFORNIA Statutes, Section 1871.2(a) states: "For your protection California law requires the following to appear on this form. Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."

Name of Employer

Address

Signature Telephone Number

Title Date

MAP010 51065-1217
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 Garrison Property and Casualty Insurance
Company
LIST OF PROVIDERS/
EMPLOYERS

Member Name Claim Number Date of Loss

Steven T Frei 032113541 - 026 07/25/2019

Please return this form with your signed medical and/or wage authorization or personal injury protection application
forms.

Injured Person Alex Kennedy

Please list below the names and addresses of any treating providers /employers:

Name of Provider

Address

City, State, Zip

Phone Number

Fax Number

Describe Type of Treatment Being Provided

Name of Provider

Address

City, State, Zip

Phone Number

Fax Number

Describe Type of Treatment Being Provided

MAP044 52775-1217
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Name of Employer

Address

City, State, Zip

Phone Number

Fax Number

Give Occupation and Dates of Employment

CALIFORNIA Statutes, Section 1871.2(a) states: "For your protection California law requires the following to appear on this form. Any person who knowingly
presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison."

MAP044 52775-1217
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