Athletic Accident Insurance - Maricopa County Community College printable pdf download

Athletic Accident Insurance

As an athlete at a Maricopa County Community College (MCCCD) institution 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 MCCCD 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 Policy Holder__________________________ Relationship__________ Date of Birth ___ /___ /______

Insurance Company________________________________________________

Policy/ID Number_______________________________

Group Number_______________________________

Insurance Company Address_________________________________________________________________________

Street

City

State

Zip

Insurance Company Phone: (_____ )____________________ HMO______PPO______ Private/Other _________

**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/Medical Conditions _____________________________________________________

Athletic Accident Insurance - Maricopa County Community College

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