THIS FORM IS NOT TO BE COMPLETED BY THE STUDENT!
PROMPTLY SEND THIS COMPLETED FORM TO RISK MANAGEMENT/DISTRICT OFFICE
Copy to VP of Administration Rev. 07/2014
Today's Date: Date of Injury:
Time Injury Occurred:
Student Accident/Injury report taken by:
STUDENT INFORMATION
Student Name: Date of Birth: CSID:
Address: City: State: Zip:
Student Cell Phone #: Student Home #:
Name of your current Insurance Plan and policy number? (if applicable)
Plan name: Policy number:
Emergency Contact Name: Emergency Contact Phone:
ACCIDENT / INJURY SUMMARY
Location where accident happened:
Did anyone witness the incident? Yes No If yes, please provide witness name and phone:
Witness Name: Witness Phone:
Was first aid rendered to student? Yes No By whom?
Which body parts were injured?
Was student participating in an intercollegiate event? Yes No
If yes, was intercollegiate event: In Season Out of Season
Was student transported by ambulance? Yes No
Exactly how did accident happen?
Disposition of Student: (back to class, home, E.R.?)
Police report taken? Yes No Name of Campus Police Officer:
Student Insurance Accident form issued to student? Yes No *HIPAA form issued? Yes No
(*Form must be issued at time Student Insurance Accident form is issued.)
Date forms were issued? Date forms were received back from student?
Date both forms were either faxed to Student Insurance, (Fax: 310.826.1601) or scanned and emailed to Kyla
Robinson, (kyla@studentinsuranceusa.com
):
STUDENT ACCIDENT/INJURY REPORT
