Insurance Information
To expedite the process of payment for sport related injuries please review the following procedure. Failure to do so
will jeopardize payment and you might be totally responsible for making payment for services rendered to you.
Insurance reporting procedure is subject to change. In the event you will be notified and informed of the revised
procedure.
Before a student can participate in an NJCAA and or official organized school practice, training sessions or contest,
the student must have been given a thorough sport physical stating the student in released to participate. This
report must be given to the Athletic department to be on file.
An insurance information data sheet must be filled out by your parents or guardian in some cases by the student
themselves. This must be on file in the athletic department. These forms must be given to your parents for
completion and must be returned to the Athletic Department with- in the week of the time given. If the
completed forms have not been received by the week deadline you will be suspended from any type of
practice, game and use of the Fitness Center. Insurance claims will not be submitted until the information is
on file in the Athletic Department.
*Your family insurance is primary and makes as much of the payment as possible, includes meeting
the deductible.
Chattanooga State carries a secondary insurance. This insurance will only pay after the primary insurance has made
payment to its limit.
Secondary insurance does not pay for the following:
-illness or sickness of any mature
-accidents
-injuries before you arrive at Chattanooga State
-inures incurred while not at a recognized scheduled practice or game
Secondary insurance will not make any payment until the primary insurance has taken care of their responsible
payment. The student or their parents are responsible for taking care of primary insurance notification. Delay in
primary insurance payment because of negligence on your part and will jeopardize your ability to receive money
from secondary insurance. The student may be responsible to pay expenses out of your pocket.
Injury Report Procedure
1. When injured, immediately report it to your coach, trainer and then the athletic director so an accident report can
be filed before doctor’s appointment unless an emergency that would require immediate medical care. This must be
done and on file before
a doctor’s appointment can be made.
A) On a home contest, the athletic trainer will be responsible for filling out an injury report and
submitting to the Athletic Director that day or on the next business day.
B) On an away contest, the coach will fill-out an injury report and submit to the Athletic Director the
next business day.
2. The student will meet with the Athletic Director to receive an insurance card and set up doctor’s appointment.
The Athletic Director will provide the student with the secondary insurance information card that must be taken to
the initial visit to the providers who service the student.
Medical serves are to be informed that you that your primary insurance covers your injury.
Before secondary insurance will consider payment, your primary insurance must first pay on your claim.
Parent Insurance Information
Name:___________________________________________________father
Name:___________________________________________________mother
Address:_________________________________________________Father/Mother
__________________________________________________
Phone:_____________________________________________Father(Home)
Phone:_____________________________________________Father(Cell)
Phone:_____________________________________________Mother(Home)
Phone:_____________________________________________Mother(Cell)
Student name:____________________________________________
Sport played:_____________________________________________
Primary Insurance carrier:____________________________________
Address of insurance:________________________________________
________________________________________
Insurance Phone:____________________________________________
Insured Name: _____________________________________________father/mother
Policy number:_____________________________________________
Parent signature:____________________________________________
Date:______________________________________________________
Chatt State Athletic
Insurance Parent Recognition
Signature indicates that my parents, legal guardian or myself, has read and understand the Insurance Information
and Injury Report Information.
Student athlete signature: ___________________________________________________
Student athletic print name:____________________________________________________
Date of birth:_______________________________________________________
Todays Date:________________________________________________________
Parent signature:_____________________________________________________
Date:_____________________________________________________
*Form must be fill-out and returned before a student can participate in an official practice,
training session, or contest.
If returning form to the students coach, please send to the following emails listed:
Men’s Basketball Jay Price
jay.price@chattanoogastate.edu
Women’s Basketball Jay Price
jay.pr[email protected]
Baseball Greg Dennis
greg.dennis@chattanoogastate.edu
Softball Blythe Golden
blythe.golden@chattanoogastate.edu
