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Accidents and injuries

If you get hurt in an accident and it may be someone else’s fault, let us know. It’s important for you to complete the accidents and injuries forms. We can’t pay any of your medical bills until you do.

You must complete all 4 of these forms:

  1. Accident inquiry formDownload PDF
  2. Repayment agreementDownload PDF
  3. Statement of factsDownload PDF
  4. Authorization for the release of Protected Health Information (PHI)Download PDF

    It’s extremely important for you to fill out the PHI release form. It allows us to request your medical information so we can review your claim.

No claims will be paid until all 4 forms are completed, signed, and returned to the Culinary Health Fund. Please complete these forms and return them to us even if no one else is at fault.

If you have a lawyer, they must sign the Repayment Agreement before you turn in the form.

Why do I need to fill out these forms after an accident?

If the accident is someone else’s fault, you shouldn’t get stuck with the bills, and neither should the Fund. The other person may have to pay us back for some or all of the medical bills we cover for you.


You are in a car stopped at a traffic light and are struck by another car from the rear. You are hurt and receive medical treatment. The Culinary Health Fund pays $500 of your medical bills. You then make a claim or file a lawsuit against the insurance company of the driver of the other car, or your own car insurance. You receive a settlement of $2,000. You must reimburse the Culinary Health Fund the $500 which was paid before your settlement.

When your doctor notifies us that you have been hurt in an accident, you will receive a letter and forms in the mail asking questions about the accident.

  • Fill out and sign the forms.
  • If you have a lawyer, have your lawyer complete the forms, too.
  • Send all of the completed forms back to the Culinary Health Fund. The address is on the paperwork.

If you are involved in a lawsuit and reach a settlement, make sure your settlement includes the future cost of your health care related to the injury. Once you sign a settlement, the Culinary Health Fund may deny future claims.

Fill out, sign, and submit all of the forms. If you need help, call our Customer Service Office at 702-733-9938.