Student Accident Claim Form printable pdf download

STUDENT ACCIDENT CLAIM FORM

SUBMIT CLAIM FORM TO:

Unified Life Insurance Company

c/o Universal Fidelity Life Insurance Company

P. O. Box 304

Duncan OK 73534-0304

Phone: (800) 366-8354

Fax: (580) 252-3449

Section 1 - Notice of Injury

(To be completed by School Official)

Name of School District:

Name of School:

School Phone No:

Name of Injured Student:

□ Male

□ Female

Grade:

Time of Injury:

□ AM

□ PM

Date of Injury:

Part of Body Injured:

□ Right Side

□ Left Side

Under whose supervision?

Was accident witnessed?

□ Yes

□ No

If "Yes", by whom?

The accident happened while the student was participating in:

□ Interscholastic UIL Activity

□ Non Interscholastic UIL Activity

Specify Sport or Activity: ________________

___________________________________________________________________________

__________________________________________________________

Explain in detail how and where the injury occurred:

__________________________________________________________________________________________________________________________

Signature of School Official:

______________________________________________________________________________________________

(Title)

(Date)

******** SEE REVERSE SIDE FOR IMPORTANT CLAIM FILING INSTRUCTIONS ********

Section 2 - Parent/Guardian Statement

(To be completed by Parent/Guardian)

Name of Student:

Date of Birth:

Home Phone No:

Is student covered by any insurance plan? □ Yes □ No

If yes: Personal

□

Medicaid

□

Other

□

Name of Other Insurance:

Parent/Guardian Name:

Relationship to Student:

Mailing Address:

_________________________________________________________________________________________________________

(Street/P. O. Box)

(City)

(State)

(Zip)

Father's Name:

Father's Employer:

Name of Father's Insurance Company (Must be completed - If father has no insurance - write "None")

Does this policy insure the student?

Insurance Company:

Yes______ No ______

Mother's Name:

Mother's Employer:

Name of Mother's Insurance Company (Must be completed - If mother has no insurance - write "None")

Does this policy insure the student?

Name of Insurance Company:

Yes______ No ______

I hereby authorize any insurance company, their authorized agent, hospital, physician, employer, school official or other person who has

attended or examined the claimant to disclose, when requested to do so, all information with respect to any injury, policy coverage,

medical history, consultation, prescription or treatment, and copies of all hospital or medical records and itemized bills. A photo static

copy of this authorization shall be considered as effective and valid as the original. I swear that the above information is true and correct

to the best of my knowledge. I further understand that any person who knowingly presents a false or fraudulent claim for

payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

__________________

_____________________________________________

______________________________________________________

(Date)

(Print Name of Student)

(Signature of Parent/Guardian)

Form CLM-2 (15)

Student Accident Claim Form

Related Articles

Related forms

Related Categories