Accident Detail Form
Chickering Student Health Insurance Plan
In order to properly process
any claims for the below described accident and/or injury, please provide the
following information to the best of your ability.
Student Name:
___________________________________________________
Student ID#:
_____________________________________________________
Date of Birth:
____________________________________________________
Street Address:
___________________________________________________
City, State, Zip Code:
_______________________________________________
Phone:
____________________________ Email: ________________________
Additional insurance carrier, if applicable. Name of
carrier: ________________
Address of Carrier:
_________________________________________________
Phone # of Carrier:
___________ Policy #: ______________________________
Name
of Policyholder: _____________________ Relationship: ______________
Dates
of Coverage (Effective and Termination dates): ______________________
1. Date of accident/injury: ___________________________________________
2. Where did the
accident/injury take place? _____________________________
3. How did the
accident/injury happen? _________________________________
_________________________________________________________________
4. Was this the result of an
automobile accident? Check one: YES ___
NO ___
6. Was this the result of a sports-related injury?
If
yes, please check the appropriate selection:
Intramural
Sports ____ Intercollegiate Sports ____ Club Sports ____
7. If this
accident was the result of an intercollegiate sports injury, Please provide the
signature of the Athletic Director below:
___________________________________________________________________
Please return the requested
information to the FAX # below:
The Chickering Group
Attn: Cameron Dowdell
860-907-4672
Signature: ________________________________ Date:_______________________