Student/Summer Camp/Daycare Accident Claims

Student Accident Claim Form
(including Summer Camp Accidents)

The Archdiocese of New Orleans has obtained a Secondary (Excess) Student Accident Insurance policy in the event that a student is injured during a sponsored/supervised school or athletic activity and will require outside medical treatment, this includes Summer Camp. An Injury Claim form will be submitted on behalf of the student to A-G Administrators., the Claims Company for the accident insurance policy.  Two separate claim forms are below:  Student Accidents and another for Camp Accident. 

 

Please be advised that this coverage is excess (secondary in most situations) to all other valid and collectable insurance plans. Each student should initially provide their primary health insurance information to each medical provider at the time of treatment, as well as the Secondary (Excess) Student Accident insurance information. This policy is designed to help cover remaining balances of expenses related to a covered injury/accident that are not covered by the student’s primary insurance (including co-pays, deductibles, coinsurance, etc.) and left to patient responsibility.

 

To ensure that claims are covered under the Secondary (Excess) Student Accident Insurance, students are asked to give the billing information to each medical provider prior to every medical treatment and/or service for an Archdiocese of New Orleans sponsored/supervised activity or event, related injury. Please be sure to have the student present the identification card that is included in the packet.

 

Process:

 

1. Student injury occurs and is reported to school official, nurse, trainer, etc.
2. School official completes and signs the form and sends home with the student or sends via email to the parent (or both).
3. School official sends a copy of the form to [email protected] (for filing purposes only).
4. Parent can use the supplemental insurance card included on the form to submit to medical providers.
5. Parent must complete the form, send with proof of insurance (if they have) and submit the required invoices and explanation of benefits (EOB’s) as detailed in the attached. Recommend to parents that they submit the claim to [email protected].
6. Robin Baldassarre will get a claim setup in the new system and assist with handling reimbursements.

Student Accident Form

Summer Camp Reporting Form

Daycare Accident Claim Form
 

Our Daycare Accident insurance program covers an incidents and injuries for our students and youth enrolled in any of the Archdiocese and/or Catholic Charities of New Orleans daycare centers.  This insurance coverage is primary and does not require the parent(s)’ to file a claim against their primary health insurance.  The program does have some limits, so please read all pages of the form completely.
 
When a daycare student is injured, the parish, school or other entity should complete the Daycare Accident form and sign the top portion.  Please provide as much detail as possible on what happened and how the injury occurred. 
 
Send the signed form and all attached pages home with the student or email to their parent (or both). It is important to send all five (5) pages with the instructions, so the parents understand the documents needed to submit to our claims group.  Page 4 can be provided to any/all doctors, hospitals, etc. so they know that we have this coverage and how to submit bills to Robin Baldassarre at AG Specialty Insurance at [email protected].   Please also send a copy of the form to [email protected].

Daycare Accident Form