Parent Insurance Form - CCC-Columbus

Athlete's Name: *

Email address *

Sport: *

School: *

Dear Parent:

Our athletic accident policy, which provides insurance for your son or daughter for injuries occurring while participating in the play or practice of intercollegiate sports is “EXCESS” or “SECONDARY” to any other collectible insurance benefits.

This means that any claim for benefits must first be filed with the group insurance company providing coverage to your son or daughter through your employer or your spouse’s employer. After they have paid all available benefits, our athletic insurance company will consider remaining amounts based on USUAL and CUSTOMARY charges.

WE, AS THE SCHOOL, DO NOT HAVE THE OPTION OF WAIVING THE REQUIREMENT OF FILING WITH YOUR GROUP INSURANCE.

PLEASE NOTE:

1. Most employer’s group insurance allows dependent coverage to be continued to age 25 if the dependent is a full-time student. DO NOT drop dependent coverage while your son or daughter is participating in intercollegiate athletics.

2. Claims against your group insurance plan DO NOT increase your individual insurance premiums. THE FOLLOWING INFORMATION AND AUTHORIZATION MUST BE FULLY COMPLETED, ELECTRONICALLY SIGNED AND SUBMITED.

THE FOLLOWING INFORMATION AND AUTHORIZATION MUST BE FULLY COMPLETED, ELECTRONICALLY SIGNED AND SUBMITED

I am a: *

Name:

Date of Birth:

Address (Street, City, State & Zip Code):

Phone Number:

Work Phone Number:

Employer's Name:

Employer's Address (Street, City, State & Zip Code):

Name of Group Insurance Company:

Insurance Group Number:

Insurance Policy Number:

Mailing Address for Claims (Street, City, State & Zip Code):

Phone Number:

Is your Dependent Son/Daughter covered under the above Policy? *

Yes No

Does your insurance require a second opinion for surgery?

Yes No

Does your insurance require Pre-authorization for Services?

Yes No

Is your primary insurance an HMO?

Yes No

Is your primary insuracne a PPO?

Yes No

I am a:

Name:

Date of Birth:

Address (Street, City, State & Zip Code):

Phone Number:

Work Phone Number:

Employer's Name:

Employer's Address (Street, City, State & Zip Code):

Name of Group Insurance Company:

Insurance Group Number:

Insurance Policy Number:

Mailing Address for Claims (Street, City, State & Zip Code):

Phone Number:

Is your Dependent Son/Daughter covered under the above Policy? *

Yes No

Does your insurance require a second opinion for Surgery?

Yes No

Does your insurance require Pre-authorization for Services?

Yes No

Is your primary insurance a PPO?

Yes No

Is your primary insurance an HMO?

Yes No

I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained. *

Yes No

My son/daughter is NOT covered under my group insurance. *

Yes No

I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. I authorize release of the above insurance information to any concerned providers. A photostatic copy of this authorization shall be considered as effective and valid as the original.

Electronic Signature - Please type your First and Last Name: *

Date: *

Date Picker

* required field