Safety & Loss Prevention

Camp & Clinic Accident Claim Form

Institution: UW-____________________________

Type of Camp/Clinic ___________________

Location Code ___________________

Send Claims to the following:
Karla Buss
AON Risk Services Inc. of Wisconsin
330 E Kilbourn Ave Ste 450
Milwaukee, WI 53202-3179
ACCIDENT CLAIM
(To Be Completed By the Injured Person)
FULL NAME (INJURED PERSON)                                  
 SOCIAL SECURITY NUMBER                                              
   
STREET ADDRESS

 TELEPHONE NUMBER:
   
CITY OR TOWN, STATE, ZIP

 AGE
POLICY HOLDER'S NAME

Board of Regents of the University of Wisconsin System 		PHYSICIAN'S OR SURGEON'S NAME
STREET ADDRESS
        780 Regent St. Suite 145 		STREET ADDRESS
CITY OR TOWN, STATE, ZIP
        Madison, WI 53715 		CITY OR TOWN, STATE, ZIP
POLICY NUMBER
        64044915 		TELEPHONE NUMBER
   
WHEN WERE
YOU INJURED?
 DATE


TIME

AM/PM 		IF HOSPITALIZED, NAME OF HOSPITAL


WHEN DID YOU
CEASE WORK?		 DATE

 STREET ADDRESS
IF TOTALLY
DISABLED,
GIVE DATES		 FROM


 TO


 CITY OR TOWN, STATE, ZIP
WHEN DID OR
WILL YOU RESUME
ANY PART OF
YOUR WORK		 DATE



 HOSPITAL
CONFINEMENT
DATES

 FROM



 TO
DESCRIBE INJURIES


DESCRIBE FULLY HOW AND WHERE ACCIDENT OCCURRED (Attach Separate Sheet if Necessary)




I hereby authorize any hospital, physician, or other person who has attended me or examined me to furnish to the following Company, or their representative, all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment and copies of all hospital or medical records. A photostatic copy of this authorization shall be considered as effective and valid as the original.

Company:    Chubb Insurance Company             

Signature_____________________________________________________ Date_________________________

Updated 2/20/07

PHYSICIAN'S REPORT
(To Be Completed By the Attending Physician)

Policy Holder's Name: Board of Regents of theUniversity of Wisconsin System; Policy No. 6404-49-15 

1. PATIENT'S NAME: FULL NAME (INJURED PERSON)

 

2. NATURE OF INJURY (DESCRIBE COMPLICATIONS, IF ANY)

 

3. DESCRIBE ANY PRE-EXISITNG CONDITION OR OTHER DISEASE OR INFIRMITY WHICH MAY OR MAY NOT AFFECT PRESENT CONDITION:



OFFICE
4. GIVE DATES OF TREATMENT: HOME
HOSPITAL
5. IS YOUR PATIENT DISABLED?

___ YES

___ NO

DATE


IF YES,
___TOTAL
___PARTIAL

DATE:

ABLE TO WORK ON:


DATE: ________

RESUMED WORK ON:

DATE: _________

6. FACTORS PROLONGING DISABILITY DATE

 

7. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION?


___YES

___NO

 CONTEMPLATE DISCHARGE DATE: IF DISCHARGED, GIVE DATE:

8. AMOUNT OF YOUR BILL FOR SERVICES TO DATE:

 

PHYSICIAN'S SIGNATURE: __________________________________________________ DATE: _________________
STREET ADDRESS: _______________________________________________________
CITY OR TOWN: ________________________________________ STATE/ZIP: _________________________
TELEPHONE NUMBER: (____) _____ - _________