Student Athlete Insurance Information 2024-2025

Hiram College Student Athlete Insurance Information

2025-2026
The NCAA requires that all Hiram College student athletes provide annual proof of insurance for the coverage of athletic related injuries.

If you have questions or if you do not have primary insurance coverage and need alternative insurance options please contact Jim Johnston, Head Athletic Trainer at johnstonjw@hiram.edu.
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Student ID Number*
If you do not know or have your student ID number place 000 in the box
Student Cell*

Area CodePhone Number
Email*
example@example.com
Are you an international student? *
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Primary Phone*

Area CodePhone Number
Emergency Contact Secondary Phone

Area CodePhone Number
Emergency Contact Work Phone

Area CodePhone Number
Which sports are you planning to play?*

BaseballBasketball MenBasketball WomenCheer/STUNTCross Country MenTrack/Field MenCross Country WomenTrack/field WomenFootballGolf MenGolf WomenIce Hockey MenLacrosse MenLacrosse WomenSoccer MenSoccer WomenSoftballSwimming/Diving MenSwimming/Diving WomenVolleyball MenVolleyball WomenWrestling MenWrestling Women
Primary Care Physician
Primary Care Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician Phone

Area CodePhone Number
My insurance covers illness and accidents including athletic-related injuries in the state of Ohio?*
The NCAA requires annual proof of insurance from each athlete. I understand if my primary insurance excludes athletic related injuries, Hiram College provides a secondary policy with a $1,000 deductible plus co-pays which the student athlete is responsible to pay*
I have verified that my insurance covers Crystal Clinic orthopedic medical facilities.*
I have verified that my insurance covers University Hospital medical facilities.*
I have verified that my insurance covers Cleveland Clinic medical facilities.*
Upload a picture of your insurance card - front and back OR fill out the information below

Browse Files

Cancelof
Insurance Company Name*
ID Number
Group Numbers
Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Claims Office Phone

Area CodePhone Number
Claims Office Fax

Area CodePhone Number
Policy Holder Name

First NameLast Name
Policy Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Deductible
Policy Co-Pay
Prescription Insurance Carrier (on insurance card)
Prescription ID #
Bin #
RX Group #
Insurance Pharmacy Provider Phone (on card)

Area CodePhone Number
Should be Empty:

Hiram College Student Athlete Insurance Information