STUDENT-ATHLETE MEDICAL INSURANCE INFORMATION FORM
Please Print. Please complete all blanks and sign form. If information is not applicable, indicate the reason; e.g. deceased, divorced, unknown. Failure to complete all blanks will result in delay of processing claims.
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Name of Athlete:____________________________ Sport:_________________ Year in school: FR or SO |
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SSN:______________________________________ DOB:_____________________ Sex: M or F |
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Email Address:____________________________ Home #:________________ Cell:_________________ |
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Home Address:__________________________ City:___________________ State/Zip:_______________ |
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College Address:_________________________ City:___________________ State/Zip:_______________ |
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Father/Guardian:____________________________ SSN:__________________ DOB:________________ |
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Home Address:_________________________________ City:_________________ State/Zip:____________ |
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Email Address:_____________________________ Home #:__________________Cell #:_______________ |
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Employer:_______________________________________________ Phone#:_______________________ |
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Address:______________________________ City:___________________ State/Zip:___________________ |
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Insurance Co._____________________________ Phone #:______________________________________ |
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Address:________________________________ City:________________ State/Zip:____________________ |
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Policy #:_____________________________________ Group #:___________________________________ |
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Mother/Guardian:___________________________ SSN:__________________ DOB:________________ |
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Home Address:_________________________________ City:_________________ State/Zip:____________ |
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Email Address:_____________________________ Home #:__________________Cell #:_______________ |
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Employer:_______________________________________________ Phone#:_______________________ |
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Address:______________________________ City:___________________ State/Zip:___________________ |
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Insurance Co._____________________________ Phone #:______________________________________ |
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Address:________________________________ City:________________ State/Zip:____________________ |
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Policy #:_____________________________________ Group #:___________________________________ |
Is the company/plan listed above considered a Health Maintenance Organization (HMO)? ____Yes ____No
Does your insurance plan require a second opinion before performing surgery? ____Yes ____No
Does your insurance plan require pre-certification before admission to hospital? ____Yes ____No
All international student-athletes must purchase student health insurance. The international student should purchase student insurance prior to arriving to the United States and must purchase this insurance prior to participating in any intercollegiate sport. For more information, contact the Compliance Officer at 573-840-9669 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
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In case of Emergency Contact |
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Name:____________________________ Phone #:_______________________ Relationship:__________ |
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Name:____________________________ Phone #:_______________________ Relationship:__________ |
I hereby authorize Three Rivers College and the insurance company, or its representatives to inspect or secure copies of case history records, laboratory reports, diagnoses, X-rays, and any other documents covering this and/or previous confinements, examinations, treatments and/or disabilities. A copy of this authorization shall be deemed as effective and valid as the original.
I understand my insurance is primary (pays first) and Three Rivers College athletic insurance is secondary (pays after primary payment is complete). I also acknowledge that if the information concerning primary insurance is not accurate, or if the insurance status changes and Three Rivers College is not notified within 30 days, Three Rivers College will not be responsible for my medical charges. I also understand that I must submit a copy of my insurance card (front and back) along with this form.
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Parent/Guardian Print Name:___________________________________ Parent/Guardian Signature:_____________________________________ Date:_____________________ |
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Student Athlete Print Name:_____________________________________ Student Athlete Signature:_______________________________________ Date:_____________________ |
