Bloomsburg Sports Medicine

Intercollegiate Athletic Insurance Questionnaire


Bloomsburg University Athletic Accident Insurance Information




Accident/Injury benefits for athletes are provided on an "excess" basis. This means ATHLETES OWN GROUP INSURANCE OR THAT OF THE ATHLETE SPOUSE AND/OR PARENTS MUST BE BILLED FIRST. Benefits are available from our program only when the Athlete's coverage is exhausted or does not apply. The following information is essential to assure that expenses are adequately and completely covered by the proper insurance. Inadequate or incomplete answers will delay payment of medical bills and may jeopardize the athlete's credit rating. No medical expenses will be paid out of institutional funds without a signed, accurate questionnaire on file. It is the athlete's sole responsibility to keep the information contained in this document current.



Section 1 - Athlete Information

Name
Marital Status: MarriedSingle
Class: Fr. So. Jr. Sr.
Street Address
City/State/Zip
Date of Birth
Sex: MaleFemale
SS# - -
Home Phone
Accidental Death Beneficiary (Full Name/Relationship)



Section 2 - Parent Information

Father'sMother's
Name Name
Street Address Street Address
City/State/Zip City/State/Zip
Home Phone Home Phone
Employer Employer
Address Address
Work Phone Work Phone



Section 3 - Parent Medical Insurance or Self Medical Insurance

Father's Medical InsuranceMother's Medical Insurance
Insurance Co. Name Insurance Co. Name
Address Address
Phone Number Phone Number
Pre-Authorization Pre-Authorization
Policy Number Policy Number
Group Number Group Number
I.D. or SS# I.D. or SS#



I hereby certify that the foregoing answers are true, complete, and correct to the best of my knowledge. I also hereby authorize any Insurance Company, Organization, Employer, Hospital, Physician, Surgeon, Pharmacy, or other health care provider to release any information with respect to injury, treatment, or insurance. A photostatic copy of this authorization shall be considered as effective and valid as the original.
  Athlete Name:   Date:   Sport:




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