Insurance Forms

The following forms and necessary documentation must be must be complete and presented to Pati Smith AS SOON AS POSSIBLE. Please review he checklist to make sure you have completed all of the necessary forms.

Make sure you complete items 1-10! 

1. Athletic Insurance Information Form
(This form must be typed and completely filled out and signed by both parent/guardian if the student-athlete is under the age of 18. Do not leave any questions blank.)

 2.  Acknowledgement of Responsibility signed by parent/guardian and student-athlete Form
 3. Acknowledgement of Insurance Requirements form signed by student-athlete Form
 4. Acknowledgement of Insurance Requirements for signed by parent/guardian Form
 5. Summer Workout form signed by parent/guardian and student-athlete Form
 6. Student Athlete Authorization/Consent Form for Insruance and Medical Information Release
 7. Consults with Outside Physicians Form signed by parent/guardian and student-athlete Form
 8. Acknowledgement of Policies and Procedures

 9. Copy of Insurance card(s), include both the front and back

 10.  Summary/Schedule of Benefits
(Describes your plan's benefits and limitations for medical coverage, deductibles, out-of-pocket expenses, what percentage the insurance will pay for lab, x-rays, in-patient and out-patient services. For carriers that are PPOs, it shows the aforementioned in-network and out-of-network. If you are not in possession of this information, contact your employer's Human Resources Office or some insurance carriers have it on their website. Please do not send a book. The only information we are interested in is what may pertain to the student-athlete if he/she is injured.)