1.  School Name: ____________________________________________________________ Group #:_____________________________

2.  Insured Person: ____________________________________________________________
SSN:_____________________________

3.  Local Address:___________________________________________________

4.  Home Address: ___________________________________________________________

5.  Date of Birth: _____/_____/_____  Local Phone: (  ) ____________________________  Home Phone: (  ) ____________________________

6.  Is this claim the result of an accident:  ___ Yes  ___ No  If "yes", give date of accident: _____/_____/_____  Time of Accident: ___________

7.  Please indicate type of sport injury.  ___Intercollegiate  ___Intramural  ___Club  ___ Other 

8.  Where did the accident occur? ___________________________________________________________

  Provide detailed description of the injury or accident and how it occurred. ___________________________________________________________

  ___________________________________________________________ 

9.  When did you first consult a physician for this condition?  ___________________________________________________________

10.  Have you been previously troubled with this condition? ___ Yes  ___ No  If "yes", please provide date: _____/_____/_____ 

11.  Is patient covered for benefits by any other Group Health, Employer, Union, Welfare Plan or Parent Health Plan?  ___ Yes  ___ No

  If answered "yes", please complete the following:

  Coverage provided through: 

  Name of Person____________________________________________________   Relationship _____________________________________

  Address __________________________________________________________   Address _________________________________________

  Telephone (  ) ___________________________________________________  Telephone (  ) ____________________ Policy # _______

  Please include a photocopy of other plan identification card, if available.

12.  I hereby authorize any Insurance Company, Organization, Employer, Hospital, Physician, Surgeon or Pharmacist to release any information

  requested with respect to this claim.

  It is unlawful to knowingly provide false, incomplete or misleading facts or information regarding a claim for the purpose of defrauding

  or attempting to defraud to receive benefits.  Penalties may include imprisonment, fines, denial of benefits and/or civil damages.

  For your protection, California law requires the following to appear on this form:  Any person who knowingly presents a false or

  fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

Signature of Insured  __________________________________________________________
   Date _____________ 20__________

Signature of College Official __________________________   Title ______________________________   Date _____________ 20__________

I hereby certify that the statements made are correct to the best of my knowledge and believe that the above named claimant was insured hereunder at the time of the accident, and that the above injury was sustained while participating in official activities under adequate organizational supervision on _______________.

  Date of Injury