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Claim Form

If you have incurred medical expenses, you are required to complete and submit a Student Assurance Services, Inc. company claim form. Only one claim form is needed for each accident.


1. Select and complete the claim form located under your
    school's webpage. To locate your school, select "Find My
2. Select the state where the school is located.
3. Search and select the school's name.
4. From your school's webpage, select "Claim Form".
    Note: You can select and print an ID Form.

How to Complete and Submit a Claim Form

1. Parents notify the school immediately if the injury is School
    related, the school administrator must complete and sign
    Part A of the claim form.
2. Parents must complete and sign Part B of the claim form.
    Answer all questions.
    Note: If this injury is NOT school-related, then you may
    complete both Part A and Part B of the claim form.
3. Parents must submit itemized bills (often called UB04 or
    CMS 1500) that contain date of service, procedure code,
    diagnosis code, federal tax ID number, and NPI number of
    the hospital or doctor. Balance due statements cannot be
    Note: You can leave a COPY of the claim form and this form
    with the provider or facility. Providers may submit itemized
    bills directly to SAS on the student's behalf. However, some
    providers may require payment at the time service is provided
    or may send the bill directly to the parent.
4. Parents must submit explanation of benefits (EOBs) from the
    student's primary insurance coverage showing write-offs,
    copays, coinsurance, deductibles and payments. This plan pays
    second to other dental or health insurance coverage.
    (Coverage is primary in ID, SD and primary if parent-paid
    in IL)
5. Mail, fax or email the completed claim form, copies of itemized
    bills, and other insurance EOBs to:
          Student Assurance Services, Inc.
          P.O. Box 196
          Stillwater, MN 55082
          Fax: 651-439-0200

Tips for Submitting Claims

If the accident occurred at school or during a school
   sport/activity, the claim form must be signed and
   PART A completed by an authorized school official -
   contact your school in this situation.

• If you fax claim information, always include a cover sheet
   with your name and phone number.
• To avoid processing delays, please submit a fully
   completed claim form. Answer all questions pertaining to
   your injury.
• Balance due statements or receipts cannot be processed.
• Submitting the claim form and related bills is your
   responsibility. Do not rely on the school or health care
   provider to send claim information.
• Policies have timely filing deadlines, generally one (1) year
   and ninety (90) days from the date of service to submit
   proof of loss (may vary based on state law requirements).

Mailing Address:
Student Assurance Services, Inc.
P.O. Box 196
Stillwater, MN 55082

Customer Service:
Toll Free (800) 328-2739
Fax (651) 439-0200

Email to submit a claim:

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