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P.O. Box 979
Student Accident Claim Form
Valley Forge, PA 19482
610.933.0800
Please complete and submit to A-G Administrators with
Fax: 610.935.2860
itemized medical bills and primary insurance explanation of
www.agadministrators.com
benefits. For questions, please contact A-G Administrators.
College/University _____________________________________________________________________________________
Student’s Name________________________________________________________________________________________
FIRST NAME MIDDLE INITIAL LAST NAME
Date of Birth ______________ Sex: Male Female Cell Phone __________________________________________
Email Address _______________________________________________________________________________________
School Address _______________________________________________________________________________________
STREET CITY STATE ZIP
Home Address ________________________________________________________________________________________
STREET CITY STATE ZIP
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ACCIDENT INFORMATION
Place of Accident _________________________________________________ Accident Date __________________________________
Body Part Injured __________________________________ Activity ______________________________________________________
Nature of Injury — Details of What Happened __________________________________________________________________________
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INSURANCE INFORMATION
Does the claimant have primary insurance? Yes No (Attach separate sheet if necessary.)
Insurance Company Name & Address _____________________________________________________________________
Policy Number __________________________________________ ID# _________________________________________
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AUTHORIZATION
AFFIDAVIT: I verify that the statement on other insurance is accurate and complete. I understand that the intentional furnishing of incorrect
information via the U.S. Mail may be fraudulent and violate federal laws as well as state laws. I agree that if it is determined at a later date
that there are other insurance benefits collectible on this claim I will reimburse A-G Administrators to the extent for which A-G Administrators
would not have been liable.
AUTHORIZATION TO RELEASE INFORMATION: I authorize any Health Care Provider, Doctor, Medical Professional, Medical Facility,
Insurance Company, Person or Organization to release any information regarding medical, dental, mental, alcohol or drug abuse history,
treatment or benefits payable, including disability or employment related information concerning the patient, to A-G Administrators and its
designees.
PAYMENT AUTHORIZATION: I authorize all current and future medical benefits, for services rendered and billed as a result of this claim,
to be made payable to the physicians and providers indicated on the invoices.
STUDENT SIGNATURE (Parent or guardian, if participant is a minor) Date
SCHOOL OFFICIAL SIGNATURE Title Date
ACC 07/14
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