Fillable Accident Report Form (Page 3 of 4) in pdf

000168139/ JSX0000026518100

9. Have you had a similar injury in the past?

Yes

If yes, describe and give dates:____________________________________________________________________________

10. Name, address and phone number of physician who treated you for previous injury: ____________________________

________________________________________________________________________________________________________

11. Are you covered by any other medical expense benefits plan?

Yes

If yes, give the names of the plan(s) and the person(s) through whom you are insured and their relationship to you:

________________________________________________________________________________________________________

IF YOU HAVE NO OTHER INSURANCE ON YOUR CHILD, BUT YOU AND/OR YOUR SPOUSE ARE

EMPLOYED FULL TIME, PLEASE PROVIDE A STATEMENT FROM THE EMPLOYER(S) INDICATING

YOUR CHILD IS NOT COVERED BY ANY INSURANCE OFFERED THERE.

All BenefiTS will Be mAde PAyABle To ProviderS of ServiCe involved, unleSS ACComPAnied By PAid reCeiPTS.

THiS iS EX ESS mediCAl CoverAGe.

I hereby authorize any physician, hospital, or other medically related facility, insurance company, or other organization, institution or person that has any records of

knowledge of me, and/or the above named claimant, to disclose, whenever requested to do so by K&K Insurance/Specialty Benefits and/or Nationwide Life Insurance

Company or its representative, any and all such information. A photocopy of this authorization shall be considered as effective and valid as the original.

Any person who knowingly and with intent to defraud any insurance company or other person files claim forms for insurance containing any materially false

information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Date_________________________

Parent/Guardian Signature________________________________________________________________

SECTION II

(TO BE COMPLETED BY PARTICIPATING SCHOOL)

fAilure To ComPleTe THiS form in full

mAy reSulT in An unneCeSSAry delAy in THe ProCeSSinG of THiS ClAim.

1. Students Name: Last _________________________________ First _____________________________ MI _________________

2. Date of Accident _____________________________________________________________________________________________

3. Activity______________________________________________________________________________________________________

4. Nature of Injury ______________________________________________________________________________________________

Madison County

5. Name of participating SCHOOL SYSTEM or SCHOOL DISTRICT ______________________________________________

Madison Southern High School

6. Name of participating SCHOOL __________________________________________________________________________

I hereby certify the foregoing statements made by me on this form to be true to the best of my knowledge. I am aware that if any of the foregoing statements

on this form made by me are willfully false, I may be subject to penalties, which may include criminal prosecution.

SIGNATURE OF SCHOOL OFFICIAL:

Calvin Creech/Athletic Director

PRINTED NAME/TITLE:

625-6148

859/986-3092

PHONE:

FAX:

calvin.creech@madison.kyschools.us

EMAIL:

DATE:

Any person who knowingly and with intent to defraud any insurance company or other person files claim forms for insurance containing any materially false

information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Date_________________________

Policyholder (School Official) Signature ____________________________________________________

1675 04/11