School Report Of Accident
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1
2Send this claim form, PRIMARY INSURANCE
SCHOOL’S REPORT OF ACCIDENT
EXPLANATIONS OF BENEFITS, and ITEMIZED BILLS to:
Complete this form and return within 90 days of the accident. Please send itemized
A-G ADMINISTRATORS, INC.
bills only; balance due bills cannot be processed. Only one form is necessary per
P.O. BOX 979, VALLEY FORGE, PA 19482
accident. Show school name and policy number on additional bills.
Fraud Warning: Any person who, knowingly and with intent to defraud, or helps commit a fraud against, any insurance company
or other person: (1) files an application for insurance or statement of claim containing any materially false information; or (2) conceals
for the purpose of misleading, information concerning any material fact thereto, commits or may be committing a fraudulent insurance
act, which is a crime and subjects such person to criminal and/or civil penalties. For residents of the following states, please see
end of the form: California, Colorado, District of Columbia, Florida, New York, Tennessee, Texas or Virginia.
STUDENT’S SOCIAL SECURITY NUMBER
Name of
Policy No.
School
School System_________________________________________________ Name of Student _______________________________________________
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Student Covered:
Schooltime
24 Hr.
Dental
All Sports
Football
Student’s Birthdate___________________________ Grade________
Name & Address of Parent or Guardian ____________________________________________________________________________________________
2. COMPLETE details of accident ______________________________________
1. Date & Time
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AM
PM
of Accident
______________________________________________________________
3. Nature of Injury_______________________________________________________________________________________________________________
4. Did accident occur while:
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(a) Attending school during hours and days school in session?
No
Yes On home premises?
No
Yes
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(b) Traveling to or from school?
No
Yes If yes, was student on usual and direct route?
No
Yes
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(c) Engaged in a school sponsored and supervised activity?
No
Yes Name & place of activity ___________________________________________
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(d) Was student participating in an Intramural sport?
No
Yes An Interscholastic sport?
No
Yes What sport? ________________________
5. Names and addresses of attending physicians _______________________________________________________________________________________
I hereby certify that the above answers are complete, true, and correct to the best of my knowledge and belief.
_________________________________________________
_______________________ ________________________
SIGNATURE OF SCHOOL OFFICIAL
TITLE
DATE
(Required on all claims except 24 hour coverage)
__________________________________________________________________________ ________________________
SIGNATURE OF PARENT OR GUARDIAN
(Parent please complete reverse side of claim form)
DATE
PHYSICIAN’S OR DENTIST’S REPORT
1. Nature
of Injury
2. Date of First Treatment _______________
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3. Has patient ever had the same or similar condition?
No
Yes If yes, state when and describe ____________________________________________
___________________________________________________________________________________________________________________________
4. Nature of Surgical Procedure, if any & procedure code ________________________________________________________________________________
5. Dates of
______________________________ Description: ___________________________________________ Charge:
__________________
Treatment: ______________________________
___________________________________________
__________________
______________________________
___________________________________________
__________________
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TOTAL
6. Has patient been discharged from treatment?
No
Yes If yes, give date ______________________
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CHARGE:
7. Was patient confined to a hospital?
No
Yes If yes, give name & address of hospital & dates confined
_____________________________________________________________________________________
8. TO WHAT OTHER INSURANCE COMPANY HAVE YOU REPORTED THIS CLAIM?
(INCLUDE NAME & ADDRESS)
_____________________________________________________________________________________
9. List teeth involved and indicate on chart._____________________________________________________
_____________________________________________________________________________________
10. Describe condition of injured teeth prior to accident.
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1. CARIOUS
2. FILLED
3. WHOLE
4. CAPPED OR ARTIFICIAL
5. SOUND & NATURAL
NOTICE OF A LEGAL REQUIREMENT: Insert your Tax Identification
COMPANY USE ONLY
Number as required by Section 6041 of the Internal Revenue Code.
(CLAIM CANNOT BE PROCESSED WITHOUT THIS INFORMATION.)
_______________________________________________________ _______________________
PHYSICIAN’S SIGNATURE
DATE
PHYSICIAN’S NAME
AND ADDRESS
NAME (PLEASE PRINT OR TYPE)
ADDRESS
K-12 03/06
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