Online Claim Form

Please complete the online form in detail to ensure proper handling. A claim form should be completed and submitted to Student Assurance Services as soon as possible (not to exceed 1 year and 90 days from the date of injury). Click the "SUBMIT" button at the bottom of the page to send the completed claim form electronically to Student Assurance Services.

There is a timely filing period of one year and ninety days. Do NOT wait to send information as this may result in claim denial. This plan is supplemental to all other insurance coverage. You must file a claim with your other insurance first.

Part A — Notice of Injury:

*Denotes required fields.

Time of Day *AMPM

Was He/She a Witness? *YesNo

LeftRight

Electronic Signature (By College Official):

BY ENTERING MY NAME BELOW, I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS CLAIM FORM AND WARRANT THAT ALL OF THE INFORMATION I HAVE PROVIDED ABOVE IS TRUE, COMPLETE, AND ACCURATE.

NOTE: Upon submission, an email will be sent to the student to complete Part B and Part C (if applicable) of this claim form. The claim will not be processed until all parts are completed.