Student Accident Claim Submission

Student Accident Claim Submission
NOTE: As part of the Educator Resources team, we will be glad to serve and support you through the claims process. We act as the advocate and communicator with the carrier and claim company on your behalf. They will be the ones making decisions on claims being approved, re-processed, or denied for reimbursement. Our job is to assist and advocate for your case!

Please review the Claims Service Process document for more information on Educator Resources' role.
Today's Submitting Date

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2 digit month, 2 digit day, 4 digit year
Policy Information
School or Organization Name
Policy Number
If known
City
State
Person Submitting This Form
Is the person submitting the same as the patient?
Relationship to member. I am their...
Submitter's Name

First NameLast Name
Submitters Email
example@example.com
Submitter's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient Information
Patient Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender
Patient/ Parent/ or Guardian's Name
Patient/ Parent/ Guardian's Name
Patient/ Parent/ Guardian's Phone Number
Format: (000) 000-0000.
Patient/ Parent/ Guardian's Email
example@example.com
Document Uploads
Claim Form Upload

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Bills, Receipts, Medical Paperwork Upload

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Message or Instructions
Disclaimer - Student Accident Claims Service Overview

How We Assist:
- Facilitate Document Delivery: Serve as a direct channel to convey claim forms, primary EOBs, medical records, receipts, and carrier requests between the insured and the insurance carrier.
- Provide Advocacy & Guidance: Educate clients on the claims process, assist with filling out claim forms, and guide documentation requirements.
Important Limitations:
- We are not the claim company: We are limited in our capacity as a broker.
- No Claim Decisions: Do not make approval or denial decisions on claims.
- No Direct Record/Bill Requests: Cannot request bills or medical records from healthcare providers due to HIPAA regulations; insureds must obtain and submit these directly.
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Student Accident Claim Submission

Policy Information

Person Submitting This Form

Patient Information

Document Uploads