Form Cf2014 - Notification Of Injury Or Sickness - Student Insurance Medical Claim Form

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Underwriting Company:
When Completed, return this form to the Plan Administrator:
Kenyon College (Self-Funded) – Student Health Insurance Plan
Special Risk Claims
National Guardian Life Insurance Co. – Intercollegiate Sports
Commercial Travelers Mutual Ins. Co.
70 Genesee St., Utica NY 13502
Toll Free: 800-756-3702
NOTIFICATION OF INJURY OR SICKNESS - STUDENT INSURANCE MEDICAL CLAIM FORM
(Please Print)
COLLEGE/UNIVERSITY: _____KENYON COLLEGE_______________________________
POLICY NO: ________________
Student Name:________________________________________________________________________
___Male ___ Female
Student ID No.: ___________________________________________
Date of Birth: ______________
Current Address: _____________________________________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
If Claim is for Dependents:
Name of Dependent: ______________________________________________
Relationship: ____________________________
Male
Female
Date of Birth: ____________________
SSN: __________________________________
1. Date of Injury (or) onset of Sickness: ____________________________ When was physician First Consulted? _______________
2. Nature of Injury (or) Illness: _________________________________________Part of Body Injured __Left __Right ___________
3. If Injury, (a) how and where did accident occur? __________________________________________________________________
(Please use back of Claim Form if Needed)
(b) Were you practicing or playing any intercollegiate (between rival colleges) sport at the time of the Accident? ___Yes ___No
If “Yes”, name the Sport: _______________________
Approved by: ______________________________________
(Athletic Trainer or Director)
__
__
4. Were you treated and/or referred by the Student Health Center?
Yes
No If “Yes”, date: ___________________________
Referred by: ______________________________________________________________________________________________
(
College Physician or College Nurse)
Have you suffered same or similar condition in the past? ___Yes ___No If “Yes”, and if you were treated for it,
5.
please give name and address of the physician who treated you.
Name: _____________________________________________________________
Date Treated: _______________________
Address: _________________________________________________________________________________________________
6. Was injury the result of a motor vehicle accident? ___Yes ___No
7. Was the injury or sickness a result of your employment? ____Yes ____No
8. (a) Do you, your spouse or your parents have any other insurance or medical plan that covers this condition, either Group, Individual
Automobile, Medical or Liability? ___Yes ___No
I hereby authorize any physician, hospital, company, employer or organization to release any information regarding the medical history, treatment or
benefits payable for this claim to the Insurance Company stated above or its authorized benefit Plan Administrator. A photocopy of this authorization
shall be as valid as the original. I agree that all information provided in this document is accurate and complete to the best of my knowledge. I
understand that any incorrect or undisclosed information can result in duplicate payments creating a substantial overpayment. Such overpayment will be
the obligation of the undersigned, with responsibility to reimburse in full, upon request, all amounts deemed refundable. I also authorize the Insurance
Company stated above or their representatives to pay all bills in connection with this claim directly to the doctor, hospital or any other persons rendering
service, and such payment shall release the Insurance Company from liability as to amounts so paid. Any person who, with intent to defraud or
knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is
guilty of insurance fraud. I hereby CERTIFY that I have read the answers to all parts of this form and to the best of my knowledge and belief
the information is complete and correct as given herein.
Signature:________________________________________________________
Date: _______________________________
(Please Print, Sign and Date Completed Claim Form)
CF2014 –Kenyon (WFIS)
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