STUDENT ACCIDENT CLAIMS

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 and Claim Form All data must be completed and returned to the regional contact responsiblefor 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 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 Any medical bills that are received regarding the student s accident must be forwarded to AIG-Linda Labrasca and Jabari Lewis 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 The maximum benefit payable under the Student Accident Plan is $3000 Claims above that amount are now the responsibility of the student unless the College has liability in the accident Medical bills above the $3000 limit are no longer transferred and paid under General Liability 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: 3179177117 Fax: 3179177117 Email: jlewis309@ivytechedu Broker: Arthur J Gallagher Linda Labrasca Phone: 6302854383 Fax: 6302854139 Email: linda_labrasca@aj gcom Claims ($3 000 Maximum) AIG Accident and Health Education Markets Phone: 8777755430 Fax: 8564867228

STUDENT ACCIDENT PAPERWORK The College provides accident insurance with a maximum benefit payable of $3000 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: o 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 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 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 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 $3000 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) Region Name Home Address Phone City/State Report Completed Incident Location /Time of Incident Instructor/Supervisor 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 INJURIES WHICH OCCUR WHILE PERFORMING DUTIES IN A WORK-STUDY PROGRAM FALL UNDER WORK 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 CONTACT INFORMATION FOR CLAIMS COMPANY AIG Accident & Health Education Markets PO Box 26050 Overland Park KS 66225 Ph) 8777755430 Fax) 8564867228 Instructor/Staff Signature Student Signature

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 CLAIM FORM COMPLETE IN DETAIL TO ENSURE PROMPT HANDLING Name of School Policy Number Birth IVY TECH COMMUNITY COLLEGE -ACCIDENT ONLY PLAN CHH8046914 Insured s Name Present Address I LAST NAME FIRST NAME MI INSURED S STUDENT ID# SUBSCRIBER ID# PHONE NO AND STREET CITY OR TOWN STATE ZIP + 4 Home Address NO AND STREET CITY OR TOWN STATE ZIP + 4 if claim for dependent give dependent s name relationship to insured DOB 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 #: ID # 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 of accident or sickness 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 6 Give name of all other physicians consulted 7 Hospitalized? If so where and what dates Where? From: To: 8 Health Center referral? [] Yes If yes attach referral to claims form [] No 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 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 If Authorized Representative Relationship to Patient STREET CITY STATE Zip + 4 99100 Rev (8/09) ITEMIZED BILLS FOR MEDICAL EXPENSES MUST BE ATTACHED NUFIC-GEN

PLEASE GIVE THIS SHEET TO THE PROVIDER S OFFICE The patient was injured while fulfilling course requirements for an Ivy Tech class Itemized bills MUST be sent for consideration to the insurance carrier listed below: AIG Accident and Health Education Markets PO Box 26050 Overland Park KS 66225 Ph) 8777755430 Fax) 8564867228 Student s Name: Policy Number: CHH8046914