Parent's Insurance Form

Athlete Information

Athlete's Name Sport

Address

City                                                 State                Zip

Select One: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

DOB: Month: January February March April May June July August September October November December / Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year: 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995

PLEASE NOTE:

Our athletic accident policy, which provides insurance for your son or daughter for injuries occurring while participating in the play or practice of intercollegiate sports is "EXCESS" or "SECONDARY" to any other collectible group insurance benefits. This means that any claim for benefits must first be filed with the group insurance company providing coverage to your son or daughter through your employer or your spouse/s employer. After they have paid all available benefits, our athletic insurance company will consider remaining amounts based on USUAL and CUSTOMARY charges.

WE, AS THE SCHOOL, DO NOT HAVE THE OPTION OF WAIVING THE REQUIREMENT OF FILING WITH YOUR GROUP INSURANCE.

Please understand:
1. Most employers' group insurance allows dependent coverage to be continued to age 23 if the dependent is a full-time student. DO NOT drop depended coverage while your son or daughter is participating in intercollegiate athletics. Many companies will allow you to change the area of coverage for your son or daughter.
2. Claims against your group insurance plan DO NOT increase your individual insurance premiums.

THE FOLLOWING INFORMATION AND AUTHORIZATION MUST BE FULLY COMPLETED AND RETURNED BY THE INSURANCE POLICY HOLDER.

Insured Information:

Please select the individual listed as the insured on your primary/personal plan and complete all information. Father Mother Guardian Spouse Self
Insurers Full Name:	Insurers Date of Birth: Month: January February March April May June July August September October November December / Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year: 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999
Insurers Home Address
City                                                 State                Zip
Select One: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Home Phone #	Cell Phone #
e-Mail
Please list other parent full name, Cell # and Email Address
Other Parent Full Name:	Other Parent Cell Phone #
Other Parent e-Mail

Employer Information:

Employer Name	Work Phone #
Address
City                                                 State                Zip
Select One: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Group Insurance Information:

Name of Group Insurance Company:	I.D. #:	Group #:
Which hospital is In-Network with your insurance? (Select One) Baptist Methodist St. Francis

Claims Information:

Address

City                                                 State                Zip

Select One: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Phone

Detailed Insurance Information:

Does your insurance require:	A second opinion for surgery?	Yes No
	Is your primary insurance an HMO?	Yes No
	Referral or Pre-authorization for services?	Yes No
	Is your primary insurance a PPO?	Yes No
Does your insurance cover:	ER Services in the Memphis area?	Yes No
	MRIs in the Memphis area?	Yes No
	CT Scans in the Memphis area?	Yes No

Does your insurance company require MRIs and CT Scans
to be performed with the first 24 hours after an injury? Yes No

What is your deductible?

Do you have a co-pay? Yes No - If yes, how much?

Name of athlete's primary care physician

Office Phone #

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I hereby authorize a claim to be filed on my behalf under the above group medical policy in the event an athletic injury is sustained by my son or daughter. I hereby certify that the answers provided are true, complete, and correct to the best of my knowledge. A photostatic copy of this authorization shall be considered as effective and valid as the original.

Date Parent