Group Claim Form -- K-12 Accident Medical -- Risk Strategies

Insured's Information

Last Name *

First Name *

MI

U.S. Mailing Address *

City *

State *

Zip *

Date of Birth *

Gender

Male

Female

Phone Number *

School ID Number *

Nature of Injury *

Date of Injury *

Was Accident due to Employment? *

Yes

No

Have you ever been treated for this condition(s) before? *

Yes

No

Section 1 - Accident Information

Please state how, when, and where accident occurred *

Is the injury related to participation in intercollegiate sports?

Yes

No

Section 2 – Other Insurance Information

Do you have other insurance, including, but not limited to group or individual health and/or accident, government plan, or automobile?

Yes

No

If yes, please provide the information below.

Section 3 – Authorizations

If under the age of 18, please provide Parent / Guardian’s information below.

Name of Parent

U.S. Mailing Address - Number and Street Name (or PO Box #)

Authorization and Release Information

I authorize any Health Care Provider, Insurance Company, Employer, Person or Organization to release information regarding medical, dental, mental, alcohol or drug abuse history, treatment or benefits payable, including disability or employment related information, to Administrative Concepts, or their employees and authorized agents for the purpose of validating and determining benefits payable. A photocopy of this authorization shall be as valid as the original. I certify the above information to be true and correct.

Signature *

Date *

Authorization to Pay Provider

I authorize payment of charges associated with this incident directly to the physicians or providers. I further certify that the foregoing information is true and correct.

Signature *

Date *

Section 4 - Organization / Program

To be completed by the Organization / Program

Name of Organization / Program *

Policy Number * T5MP-054064-

U.S. Mailing Address

Phone Number

Signature

Date