Accident Report Form Page 2
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4000168139/ JSX0000026518100
STUDENT OR ATHLETE
ACCIDENT CLAIM FORM
Excess Coverage
K-12 ACCOUNTS
CLAIMS DEPARTMENT
1712 Magnavox Way, P.O. Box 2338 | Fort Wayne, IN 46801-2338
Ph:800-237-2917 | Fax: 260-459-5915
California License #0334819
INSTRUCTIONS FOR FILING
NOTE:
Claim Form must be fully completed and signed. File your claim promptly. Failure to do so could result in a denial of coverage.
Basic Procedures for Submitting Statement of Claim
1. A school official will complete their portion and then give the claim form to the student’s or athlete’s
parent(s)/guardian(s) for completion.
2. The student’s or athlete’s parent(s)/guardian(s) will complete the appropriate portion of the form. Attach any related
medical bills and primary insurance explanation of benefits and forward to K&K Insurance Group, Inc.
To the Student or Athlete/Parent/Guardian
If you are attaching related medical bills, these bills must show the patient's name, condition (diagnosis), type of
treatment given, date the expense was incurred and the charges made. For hospital charges, this would be a UB04
and for the physician/ancillary charges, this would be a CMS1500. The medical providers may also bill K&K Insurance
Group, Inc. direct at the address above.
SECTION I – TO BE COMPLETED BY CLAIMANT’S PARENT(S)/GUARDIAN(S)
1. Student’s Name
Last:
First:
MI:
n
n
2. Date of Birth:
SS#
Sex:
Male
Female
3. Student’s grade in school:
4. Home Address
Street:
City:
State:
Zip:
Parent(s)/Guardian(s) Home Phone:
n
n
5. Date of Accident:
Time of Accident:
AM
PM
Nature of Injury:
Describe exactly how accident happened:
6. Nature of activity and location during which the injury occurred (check all boxes which apply):
n
n
n
Pre-Kindergarten
Elementary School
Middle School
n
n
n
High School
Cafeteria
Classroom Activities
n
n
Interscholastic Sports
Intramural Sports
Name of Sport, if applicable:_______________
n
n
n
Club Sports
Physical Education Class
Other Activity (specify)_______________
n
n
n
During Practice
During Play
During Travel To or From the Event
Nature of Your Participation:
n
n
n
Student
Volunteer
Student/Manager
n
n
n
Athletic Participant
Cheerleader
Band Member
n
Other (specify)_______________________________________________________________________________________
n
n
7. Transfer Student?
Yes
No
If yes, please identify the former school name: ______________________________________________________________
8. Name, address and phone number of physician who first treated you: ________________________________________
1675 04/11
____________________________________________________________________________________________
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