Athletic Accident Form Page 2
Download a blank fillable Athletic Accident Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Athletic Accident Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Athletic Accident Claim Form
P.O. Box 979
Valley Forge, PA 19482
Please complete and submit to A-G Administrators with
610.933.0800
itemized medical bills and primary insurance explanation of
Fax: 610.935.2860
benefits. For questions, please contact A-G Administrators.
Stephen F. Austin State University (Policy# 425723)
College/University _____________________________________________________________________________________
Athlete’s Name________________________________________________________________________________________
FIRST NAME
MIDDLE INITIAL
LAST NAME
SOCIAL SECURITY #
Date of Birth ______________ Sex:
M
F Cell Phone ____________________
Email Address __________________________________________________________
P.O.Box 13010 SFA Station
Nacogdoches
Tx
School Address _______________________________________________________________________________________
75962-3010
STREET
CITY
STATE
ZIP
Home Address ________________________________________________________________________________________
STREET
CITY
STATE
ZIP
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACCIDENT INFORMATION
Sport _________________________________________________ Accident Date_________________________________
Circumstance:
Game
Practice
Conditioning
Type of Injury:
Intercollegiate
Club Sport
Intramural
Body Part Injured __________________________________ Place of Accident____________________________________
Nature of Injury — Details of What Happened _______________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INSURANCE INFORMATION
Does the claimant have primary insurance?
Yes
No (Attach separate sheet if necessary.)
Insurance Company Name & Address _____________________________________________________________________
Policy Number __________________________________________ ID# _________________________________________
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORIZATION
AFFIDAVIT: I verify that the statement on other insurance is accurate and complete. I understand that the intentional furnishing
of incorrect information via the U.S. Mail may be fraudulent and violate federal laws as well as state laws. I agree that if it is
determined at a later date that there are other insurance benefits collectible on this claim I will reimburse A-G Administrators
to the extent for which A-G Administrators would not have been liable.
AUTHORIZATION TO RELEASE INFORMATION: I authorize any Health Care Provider, Doctor, Medical Professional, Medical
Facility, Insurance Company, Person or Organization to release any information regarding medical, dental, mental, alcohol or
drug abuse history, treatment or benefits payable, including disability or employment related information concerning the patient,
to A-G Administrators and its designees.
PAYMENT AUTHORIZATION: I authorize all current and future medical benefits, for services rendered and billed as a result
of this claim, to be made payable to the physicians and providers indicated on the invoices.
ATHLETE SIGNATURE
Date
(Parent or guardian, if participant is a minor)
ATHLETIC DEPT. OFFICIAL SIGNATURE
Title
Date
ACC 11/09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business