Proof Of Claim Form
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1
2PROOF OF CLAIM
NOTICE: Anyone who knowingly misrepre-
Mail completed form to:
sents or falsifies essential information re-
This form should be completed and
quested by this form may upon conviction
STUDENT ASSURANCE SERVICES, INC.
submitted to the Company within 90
be subject to fine or imprisonment.
P.O. BOX 196
days from date of injury.
STILLWATER, MINNESOTA 55082
CLAIM PROCEDURE:
1.
A school official must complete PART A*.
3.
If dental charges — have statement completed on Page 2.
2.
The Insured’s parents or guardian must complete PART B.
4.
See Page 2 for important claim procedures.
PART A: NOTICE OF INJURY
1.
Name of School _____________________________ School District Name _____________________________________
School Address ______________________________________________________________________________________
(City)
(State)
(Zip)
2.
Name of Insured _____________________________________________________ Grade _________________________
AM
PM
3.
Date of Injury ____________________
4.
Under whose supervision? _____________________________ Was he/she a witness? _________________________
5.
The accident was incurred while the Insured was participating in:
INTERSCHOLASTIC SPORTS
NON-INTERSCHOLASTIC SPORTS
Practice
What sport?
Travel to/from school
Non-school activity
Game
In classroom
Other – Activity?
Travel
____________________________
Physical Education _________________________
On school grounds
R
L
6.
Part of the body injured ________________________________
7.
Describe in detail how and where the injury occurred _______________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Reported by _________________________________________________________________________________________
(Signature of School Official)
(Title)
(Date)
(*Part A may be completed by the parent if Full-Time Coverage was purchased.)
IMPORTANT INFORMATION ON Page 2
PART B: PARENT STATEMENT
1. Students Name _______________________________________________________ Birthdate __________________________
_______________ - ____________ - _____________________
Students Social Security #
Parents Name _____________________________________________ Relationship to Insured ______________________
Mailing Address ________________________________________________________________________________________
(Street, Route, or Box)
(City)
(State)
(Zip)
2. Home phone number ____________________________
3. Father’s Occupation _________________________________________ Employer __________________________________
Mother’s Occupation _________________________________________ Employer __________________________________
4. List your family or group coverage, please.
. _______________
Name of Insurance Company ______________________________________________
Group
Individual
PolicyNo
Address ______________________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
I hereby authorize any physician, medical practitioner, hospital, clinic, other medical or medically related facility, insurance company,
or other organization, institution, or person that has any records or knowledge of the claimant’s physical or mental health, to give the
information to STUDENT ASSURANCE SERVICES, INC. To facilitate rapid submission of such information, I authorize all said
sources, to give such records or knowledge to any agency employed by the insurance company to collect and transmit such
information. A photocopy of this authorization shall be as valid as the original. This authorization expires one year from the date signed.
For electronic filing - By entering my name below I am indicating my intent to electronically sign this claim form and warrant that
all of the information provided is true, complete, and accurate.
_______________
______________________________________
_________________________________________
(Date)
(Print Name of Student/Patient)
(Signature of Parent or Guardian)
Form CLM-2 (12)
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