Student Accident Claim Form

College/University*

Student Full Name*

First NameMiddle NameLast Name

Date*

MonthDayYear

Sex*

MaleFemale

Phone Number*

Please enter a valid Cell phone number.Format: (000) 000-0000.

Email Address*

example@pbsc.edu

School Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

ACCIDENT INFORMATION

Time of Accident*

Hour Minutes

AM/PM Option

Date of Accident*

MonthDayYear

Place of accident *

Description of Accident (what happened)*

Please submit with itemized medical bills and primary insurance explanation of benefits. thank you*

attach files here

AUTHORIZATION

AFFIDAVIT: I verify that the statement on other insurance is accurate and complete. I understand that the intentional furnishing of incorrect information via the U.S. Mail may be fraudulent and violate federal laws as well as state laws. I agree that if it is determined at a later date that there are other insurance benefits collectible on this claim I will reimburse A-G Administrators to the extent for which A-G Administrators would not have been liable.

AUTHORIZATION TO RELEASE INFORMATION: I authorize any Health Care Provider, Doctor, Medical Professional, Medical Facility, Insurance Company, 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 A-G Administrators and its designees.

PAYMENT AUTHORIZATION: I authorize all current and future medical benefits, for services rendered and billed as a result of this claim, to be made payable to the physicians and providers indicated on the invoices.

Student Signature *

College Official Signature*