1 STUDENT ACCIDENT CLAIMS 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, Commercial Traveler s Claim Form and HIPAA Authorization. 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. IF THE INJURY IS A NEEDLE STICK, EXPOSURE TO BLOOD BORNE/AIR BORNE PATHOGEN OR EXPOSURE TO BODY FLUIDS PLEASE SEE INSTRUCTIONS FOR GENERAL LIABILITY CLAIMS The regional contact will fax the forms to Commercial Travelers, Charlie Vaught at Gregory & Appel and Amy Christianson at Central Office. FAX TIlE STUDENT ACCIDENT PAPERWORK IMMEDIATELY AFTER RECEIVING IT. DO NOT WAIT UNTIL BILLS ARE RECEIVED TO REPORT TIlE CLAIM. Any medical bills that are received regarding the student s accident must be forwarded to Commercial Travelers, Charlie Vaught, and Amy Christianson. Bills must be itemized in order to be paid 0tCFA, 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 i_._~s the student s responsibili~, to obtain an itemized bill. Examples of a HCFA and UB-92 are attached to the Student Accident Paperwork. 4. A copy of all forms and medical bills must be kept on file by the region submitting the claim. If an eligible expense incurred reaches the $2,500 maximum under the Commercial Travelers plan, the claim will be turned over to the College s general liability cartier for consideration. The regional contact will be notified once a claim has reached the $2,500 maximum. 6. The Student Accident forms are in the Forms section of Infonet under "Student Accident Report". The forms are also located on Campus Connect in the Health & Wellness section of the Campus Life tab. 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 IW Tech Office - of the President: Amy Christianson Phone: Fax: Broker: Gregory & Appel Charlie Vaught Phone: Fax: Claims (First $2,500): Commercial Travelers Mutual Insurance Company Phone: Fax:
2 STUDENT ACCIDENT PAPERWORK The College provides accident insurance, with a specified maximum, 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: Cutting a finger while chopping an onion in culinary arts class, Getting a fleck of metal in the eye while welding in auto body repair class, Twisting an ankle while lifting a patient in nursing class. [[ the in/ur~ is a needle stick, exposure to blood borne / air borne pathogen or exposure to body ~uids, please see an I~ Tech employee/securitf _guard for General Liability paperwork. I_f the iniurf occurred while conducting duties as a work-study, please see the regional Human Resources department ~for worker s compensation paperwork. If a student is injured while participating in a College course or College-sponsored activi,ty~ the following steps MUST be followed: 1. NOTIFY THE INSTRUCTOR OR IVY TECH STAFF IMMEDIATELY. Complete the Student Accident Report, Commercial Traveler s Claim Form and HIPAA Authorization 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 signed for claims to be considered for payment. Student Accident forms are located on Campus Connect in the Health and Wellness section of the Campus Life tab. 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 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. 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. The student accident plan does not consider sickness.
3 IVY TECH COMMUNITY COLLEGE OF INDIANA STUDENT ACCIDENT REPORT (REPORT CLAIMS IMMEDIATEL Y- DO NOT WAIT UNTIL BILLS ARE RECEIVED) Region Name Home Address Phone Incident Location Instructor/Supervisor City/State Date Report Completed Date/Time of Incident a,mo Description of Incident (how it occurred, materials/tool being handled, and what you were doing) 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 EXPOSURE TO BLOOD BORNE/AIR BORNE PATHOGENS, BODY FLUIDS AND NEEDLE STICKS MUST BE SUBMITTED ON THE "GENERAL LIABILITY" FORM. INJURIES WHICH OCCUR WHILE PERFORMING DUTIES IN A WORK-STUDY PROGRAM FALL UNDER WORKER COMPENSATION. PLEASE SEE THE REGIONAL HUMAN RESOURCES DEPARTMENT. FOR ALL OTHER STUBENT INJURIES NOT INCLUDING THE ABOVE INCIDENTS: FILL OUT THE STUDENT INJURY REPORT, HIPAA FORM, AND COMMERCIAL TRAVELERS RELEASE AND SUBMIT THE PAPERWORK TO THE REGIONAL CONTACT RESPONSIBLE FOR HANDLING STUDENT ACCIDENT CLAIMS AT THE LOCATION. THE COLLEGE S INSURANCE CARRIER FOR STUDENT ACCIDENTS IS: Commercial Travelers Mutual Insurance Co. Attn: Special Risk Claims 70 Genesee Street Utica, NY Fax: Instructor/Staff Signature Student Signature Date Date
4 NOTICE This claim form MUST be received by the Insurance Company within 90 days of the date of Injury. Benefits will be paid for eligible expenses left unpaid by other insurance or health plans. Expenses must be incurred within 52 weeks after the date of accident. CLAIM PROCEDURE 1. Have an Official of the Organization complete, date and sign PART A. 2. The Injured Person (Insured) -- or, if the Injured Person is under age 18 or is otherwise dependent, his/her Parent or Guardian -- MUST complete, date and sign PART B. 3. After PARTS A and B have been completed in full, mail the form to the address shown below within 90 days of the date of injury. 4. Send all medical bills to your other health and accident insurance company(s) first, if applicable. This can include employee plans, union plans, service contracts, H.M.O. Plans, self-insured benefit plans, etc. 5. After you have received a notice of payment, notice of denial or letter stating you have met your deductible from your other insurance company(s), forward that statement, along with copies of the original bills, to the address shown below. I 1. COMPLETE THIS FORM. 2. ATTACH ALL BILLS. 3. MAIL TO ~ Administered by: COMMERCIAL TRAVELERS MUTUAL INSURANCE COMPANY Attn: Special Risks Division Claims 70 Genesee Street Utica, New York ACCIDENT CLAIM FORM PLEASE PRINT OR TYPE Please check the correct Underwriting Company  COMMERCIAL TRAVELERS MUTUAL INSURANCE COMPANY  SECURITY MUTUAL LIFE INSURANCE COMPANY OF NEW YORK IF PARTS A and B ARE NOT COMPLETED IN FULL, THIS CLAIM CANNOT BE PROCESSED AND WILL BE RETURNED. Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime (in FL, a felony in the third degree), and in the state of New York, shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. (N/A in VA) I I PART A - This PART MUST be completed, dated and signed by an official of the Organization. 1. Name of Organization (Policyholder) 2. Policy No. Ivy Tech Community College 2009M3BI8 4. Address of Organization (Policyholder) (Street) 50 W~st Fall Creek Pkwy N. Drive 5. Name of Injured Person (Insured) (First) 3. Name of Organization or Team (if different from Policyholder) (City) (State) (Zip) Indianapolis IN (Middle) (Last) 6. Date of Accident/Injury Mo. Day Year 7. Injury Occurred: Pm~,~.... Other.r-]. Came--5~- 8. Type of ~pm-t-or Activity: 9. Explain HOW the accident and injury occurred. NOTE: If your organization uses an Accident Report Form, attach a copy of the Report. 10. Describe the nature of injury. 11. At the time of the acddenl was the Injured Person involved in an aclmty 12. Name of Supervisor of Activity underthejurisdic~on of the Organization (Policyholder)? Yes  No El 13. Was he/she a witness to the accident?. Yes  No  14. Signature of Organization Official X SR-2007(w) 15. Title of Official 16. Area Code/Telephone No. 17. Date signed
5 PART B-- This PART MUST be completed, dated and signed by the Injured Person - or if the Injured Person is under age 18 or otherwise dependent-- by his/her Parent or Guardian. PRINT HERE--- NAME OF PERSON COMPLETING FORM: Checkone: Injured Person El Parentr~ Guardian r~ Give the following informalion about ~e Injured Person: NAME OF INSURED PERSON: 1. Date of Birth 2. Male El 3. Sodal Security No. 4. Area Code/Home Telephone No. Mo. Day Year Female El 5.Address (Street) (City) (State) (Zip) 6. Employer (Name) (Address) (~t) (Cibj) (Slate) (Zip) Area Code/Employer Telephone No. 7. Is the Injured Person coveeei under any other health and/or accident insurance plan(s)? Yes El No El If YES, give the following information: Name of Other Address of Other Policy Number(s) Name of Policyholder(s) Insurance Company(s) Insurance Company(s) 8. Name of Father or Male Guardian Sodal Security No. Place of Employment Address of Employer Name of Mother or Female Guardian Place of Employment Address of Employer 9. If the Injured Person is married, give the following information: Name of Spouse Place of Employment Address of Employer " Area Code/Employer Phone No. Sodal Secudty No. Area Code/Employer Phone No. Social Secudty No. Area Code/Employer Phone No. I authorize any insurer, hospital, physician or other person who has attended or examined the Insured Person to disclose, when requested to do so, all information with respect to any injury, policy coverages, medical history, consultation, prescription or treatment, and copies of all hospital or medical records and itemized bills. A photostatic copy of this authorization shall be considered as effective and valid as the original. The above information is true and complete to the best of my knowledge and belief. I also authorize the Insurance Company checked on the reverse or its representatives to pay all bills in connection with this claim directly to the doctor, hospital or any other persons rendering service, and such payment shall release the Insurance Company from liability as to amounts so paid Any person who, knowingly and with Intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a cdme (in FL, a felony in the third degree), and in the state of New York, shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. E! Injured Person X Signature (in writing) of Responsible Party Print Name Checkone: El Parent El Guardian Date: SR-2007(w) THE BENEFIT PERIOD FOR ELIGIBLE EXPENSES IS 52 WEEKS FROM THE DATE OF ACCIDENT, EXCEPT FOR YOUTH BASEBALL, SOFTBALL AND T-BALL, WHICH HAVE A 156 WEEK BENEFIT PERIOD
6 PLEASE GIVE THIS SHEET TO THE PROVIDER S OFFICE The patient was injured on Ivy Tech s premises or while fulfilling course requirements for an Ivy Tech class. Itemized bills MUST be sent for consideration to the insurance carrier listed below: Commercial Travelers Mutual Insurance Company Atm: Special Risk Claims 70 Genesee Street Utica, NY Toll Free: Fax: Student s Name: Policy Number: 2009M3B 18