Preparticipation Physical Evaluation: Medical History Form Page 5
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5Athletic Accident Insurance
As an athlete at GateWay Community College you are provided with a secondary accident insurance policy. This
insurance policy is NOT a health insurance policy and may not be used in cases of illness. This is an accident
insurance policy that provides supplemental (secondary) coverage for all injuries sustained while
participating in intercollegiate athletics.
This means that your personal insurance (primary insurance) carrier WILL BE utilized and they will pay their
normal benefits before the school’s supplemental accident insurance will pay any benefits. For example: if you
belong to an HMO or PPO (CIGNA, Intergroup, Aetna, BC/BS, etc.), you must follow their procedure for filing a
medical claim. After your private insurance has paid its portion of the benefits, then the secondary accident
insurance will apply to the remaining portion of the medical bill. As with all insurance carriers, the supplemental
accident insurance has its restrictions and exclusions. Therefore, all claims must be filed as soon as possible with
the athletic trainer to prevent claim denial due to time restrictions. In addition, the supplemental accident insurance
is not required to pay all remaining balances after the primary insurance carrier has been utilized. If this is the case,
the remaining balance after both the primary and supplemental insurance have been utilized, is the responsibility of
the student athlete.
The athletic trainer will assist you with filing a claim with the supplemental accident insurance carrier. It is
important to note that all medical bills are the responsibility of the student athlete. It is also the responsibility of
the student athlete that all medical claims are properly filed with their own personal (primary) insurance
carrier, and with the school provided supplemental accident insurance carrier. If a medical claim is not filed
properly or the primary insurance carrier’s guidelines are not followed the student athlete will be responsible for any
and all medical bills. At times the supplemental accident insurance policy will require additional information from
the student athlete. Again this is the sole responsibility of the student athlete to follow through with all additional
requests from both the primary and supplemental insurance companies. Failure to follow through with these requests
can lead to failure and delay of any payment for medical treatments and the possibility of the student athlete going
into collections.
My signature verifies that I understand the accident insurance policy provided by GateWay Community College is a
supplemental insurance policy. I also understand that if I do not follow the claim filing procedures set forth by my
primary insurance carrier and the school provided supplemental insurance carrier, I will be responsible for all
medical bills.
Printed name: ______________________________________________ Sport: _______________________
Signature: _________________________________________________ Date: _______________________
Signature of Parent/Guardian if Student athlete is under 18:
__________________________________________________________ Date: ______________________
___ I am NOT covered under a group insurance and/or have no insurance coverage. I understand that I am
responsible for any medical bills not covered by the secondary (supplemental) accident only insurance.
___ I am covered under the following plan:
Name of Group Insurance Company: ___________________________________________________
Group #___________________ Policy #______________________________ Type ___HMO ___PPO ___Other:
Billing Address_____________________________________________________________________
___________________________________________________________________
Phone Number _____________________________________________________________________
Primary Policy Holder __________________________ DOB _____________ Relationship________
Address_______________________________________________ State_______ Zip____________
You must attach a copy of your insurance card (front and back) in order for this form to be
complete.
In case of Emergency, please notify ________________________________ Relationship________________
Home Phone _________________ Business Phone _________________ Cell Phone ____________________
Address_______________________________________________ State_______ Zip__________
Athletes Medications / Allergies _____________________________________________________
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Parent category: Medical