STUDENT ACCIDENT CLAIMS
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When a student (see instructions for the work-study program at the bottom of the page) has an accident on
campus, the student should be given the attached Student Accident paperwork. The injured student is
responsible for completing the Student Accident Report and Claim Form. All data must be completed and
returned to the regional contact responsible.for handling student accident claims so that claims can be
submitted to the insurance carrier.
Exposure claims (needle sticks and patho~,en exposures) are now handled under the Student
Accident policy.
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The regional contact will fax the forms to AIG, Linda Labrasca of Arthur J. Gallagher and Jabari Lewis in
Central Office. FAX THE STUDENT ACCIDENT PAPERWORK IMMEDIATELY AFTER
RECEIVING IT. DO NOT WAIT UNTIL BILLS ARE RECEIVED TO REPORT THE CLAIM.
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Any medical bills that are received regarding the student’s accident must be forwarded to AIG,-Linda
Labrasca and Jabari Lewis.
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Bills must be itemized in order to be paid (HCFA, UB-92). An itemized bill must contain:
patient’s name, date of service, type of service (procedure), nature of condition being treated
(diagnosis), provider’s name, provider’s address and provider’s tax identification number. It is
the student’s responsibility to obtain an itemized bill.
4. A copy of all forms and medical bills submitted must be kept on file by the region submitting the claim.
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The maximum benefit payable under the Student Accident Plan is $3,000. Claims above that amount are now
the responsibility of the student unless the College has liability in the accident. Medical bills above the
$3,000 limit are no longer transferred and paid under General Liability.
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The Student Accident forms are found in Campus Connect, in the Forms section of Infonet, under Human
Resources and titled "Student Accident Report". The forms are also located in the Student Resources section
of Campus Connect under Health & Wellness.
Students in Work-Study Program
*Students involved in work-study programs are considered employees if they are on the job when
an accident/illness occurs.
~ SEE INSTRUCTIONS ON FILING A WORKER’S COMPENSATION CLAIM
*Students involved in work-study programs are considered students at all times other than when
on the job.
Contact Information
Ivy Tech Office- of the President:
Jabari Lewis Phone: 317.917.7117
Fax: 317.917.7117 Email: jlewis309@ivytech.edu
Broker:
Arthur J. Gallagher
Linda Labrasca
Phone: 630.285.4383
Fax: 630.285.4139
Email: linda_labrasca@aj g.com
Claims ($3, 000 Maximum)
AIG Accident and Health Education
STUDENT ACCIDENT PAPERWORK
The College provides accident insurance, with a maximum benefit payable of $3,000, for injuries sustained while
enrolled and participating in a College course or College-sponsored activity. Intramural and recreational sports are
excluded from coverage. Examples of covered accidents include, but are not limited to, the following:
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Cutting a finger while chopping an onion in culinary arts class,
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Getting a fleck of metal in the eye while welding in auto body repair class,
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Twisting an ankle while lifting a patient in nursing class.
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Exposure to blood borne / airborne pathogen (ex. needle stick sustained in clinical).
!f the in/urF occurred while conducting duties as a work-study, please see the Regional Human Resources department
for worker’s compensation paperwork.
If a student is iniured while participatin~ in a College course or College-sponsored
activity, the followin~ steps MUST be followed:
1. NOTIFY THE INSTRUCTOR OR IVY TECH STAFF IMMEDIATELY.
2. Complete the Student Accident Report and attached claim form and submit it to the instructor or the person in
charge of handling the regional student accident claims at that location.
All forms must be complete and si~ned for claims to be considered for payment.
Student Accident forms~are located on Campus Connect in Student Resources section under Health
and Wellness.
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Submit itemized bills to the instructor or person in charge of handling the regional student accident claims.
The College’ s insurance carrier requires and only considers eligible expenses from an itemized bill
(HCFA 1500 or UB-92). An itemized bill MUST include the following: Patient’s name, date of
service, type of service rendered (procedure), nature of condition being treated (diagnosis),
provider’s name, provider’ s address and provider’ s tax identification number. Samples of the
necessary forms are attached. STATEMENTS OR PAST DUE BILLS WILL NOT BE
ACCEPTED. IT IS THE STUDENT’S RESPONSIBILITY TO OBTAIN AN ITEMIZED
BILL.
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When medical treatment is required as a result of a covered injury, the following page may be given to the
provider for insurance information. Not all claims are eligible under this plan. Be prepared to pay for
services rendered if the claim is denied by the College’ s insurance carrier or if the maximum of $3,000 has
been paid through the plan. The student accident plan does not consider sickness as payable under this plan.
An example of a claim considered sickness is fainting during a clinical. Filing a claim does not guarantee
acceptance and payment of claim.
IVY TECH COMMUNITY COLLEGE OF INDIANA
STUDENT ACCIDENT REPORT
(REPORT CLAIMS IMMEDIA TEL Y- DO NOT WAIT UNTIL BILLS ARE RECEIVED)
Name
Home Address
City/State
Phone
Date Report Completed
Incident Location
Date/Time of Incident
Instructor/Supervisor
Description of Incident (how it occurred, materials/tool being handled, and what you were doing)
Region
Description of Injury (part of body, type of injury)
First Aid Given? No
Yes
Procedure
By? EMS Contacted? No
Yes
Treatment Refused? No
Yes
Have you paid the provider for services? No Yes
**If you have paid the provider(s) directly, attach receipt(s) of payment along with the itemized bill(s). If you have not paid the
provider(s), payment will be issued directly to the provider(s).
Witness
INJURIES WHICH OCCUR WHILE PERFORMING. DUTIES IN A WORK-STUDY PROGRAM FALL UNDER WORKER’S
COMPENSATION. PLEASE SEE THE REGIONAL HUMAN RESOURCES DEPARTMENT. ".
FOR ALL OTHER STUDENT INJURIES:
FILL OUT THE STUDENT ACCIDENT REPORT AND CLAIM FORM
AND SUBMIT THE PAPERWORK TO THE REGIONAL CONTACT RESPONSIBLE FOR HANDLING STUDENT
ACCIDENT CLAIMS AT THE LOCATION.
~CLA1MS RESULTING FROM A MEDICAL CONDITION ARE NOT COVERED UNDER THE ACCIDENT
POLICY. FILING A CLAIM DOES NOT GUARANTEE ACCEPTANCE AND PAYMENT OF CLAIM.
Instructor/Staff Signature
Student Signature
CONTACT INFORMATION FOR CLAIMS COMPANY
AIG Accident & Health Education Markets
PO Box 26050
Overland Park, KS 66225
Ph) 877.775.5430
Fax) 856.486.7228
Date
National Union Fire Insurance
Company of Pittsburgh, Pa.
COVERAGE VERIFIED
PLEASE PRINT ALL INFORMATION
MAIL TO:
AIG, Educational Markets Mail Center
P. O. Box 26050 Overland Park, KS 66225
1-877-775-5430
SPECIAL NOTICE: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles or an insurance company commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
PART 1 - MUST BE COMPLETED AND SIGNED
Name of School Policy Number Birth Date
IVY TECH COMMUNITY COLLEGE -ACCIDENT ONLY PLAN CHH8046914
Insured’s Name I
LAST NAME FIRST NAME M.I INSURED’S STUDENT ID# SUBSCRIBER ID# PHONE Present Address
NO. AND STREET CITY OR TOWN STATE ZIP + 4 Home Address
NO. AND STREET CITY OR TOWN STATE ZIP + 4
CLAIM FORM
COMPLETE IN DETAIL TO ENSURE
PROMPT HANDLING
if claim for dependent, give dependent’s name , relationship to insured D.O.B. Are you covered (as an insured or dependent) by any other hospital and/or medical plan? [] Yes Insured [] Yes Dependent [] No If yes, please check one: [] Group [] Individual [] Automobile/Medical
If yes, also indicate name and policy number of insurance company.
Name of Insured: Policy #/Group #: I.D. # Company Have you filed a claim with the above company? [] Yes [] No
Send copies of all Explanation of Benefits showing benefits paid and/or benefits denied to the Company at the address above. Name and Address of Employer of:
[] Insured, if employed [] Spouse, if insured is married
1. Date of accident or sickness Date of first treatment. 2. Nature of sickness or injury.
3. If injury, describe how and when accident occurred and indicate if work related
Check One: [] Intramural *4. If injured in practice or play or sport, [] Intercollegiate
indicate which sport. [] Other
5.~ Have you previously been troubled with this condition?
[] Yes
[] No Date 6. Give name of all other physicians consulted
Where? From: 7. Hospitalized? If so, where and what dates To:
8. Health Center referral? [] Yes[] No If yes, attach referral to claims form.If no, please explain
PAYMENT WILL BE PAID TO THE PROVIDERS OF SERVICE (Hospital, Physician and others), UNLESS A PAID RECEIPT OR STATEMENT ACCOMPANIES THE BILL AT THE TIME THE CLAIM IS SUBMITTED
* IMPORTANT: ALL INTERCOLLEGIATE SPORTS CLAIMS MUST BE SIGNED BY AN AUTHORIZED ATHLETIC/SCHOOL OFFICIAL I hereby certify that the above injury was sustained while participating in official activities under adequate organizational supervision
Signature of College Official Title Date
DATE
To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I permit (while my claim is pending) the release of any medical information about me to the Company and its representatives. The Company’s representatives include re-insuring companies and other persons or groups performing business or legal services relating to my claim. This applies to all information about the diagnosis, treatment, or prognosis or any illness or injury I now have or have had in the past. The Company will use this information to find out if my claim is eligible. A copy of this authorization (one or which will be
given to me by the Company upon my request) will be as valid as this one.
I certify that the above information given by me in support of this claim is true and correct.
Patient’s or Authorized Representative’s Signature Date
If Authorized Representative, Relationship to Patient
STREET CITY STATE Zip + 4
