Information regarding a student injury:
In order to file an accident claim, the injured person cannot have been working as an employee at the time of the injury. If the injured person is a campus employee, a student worker, or a student sponsored by a company or agency, they will need to contact their supervisor for their Workers Comp provider information and protocol.
If the student was not working as an employee at the time of injury, please read the following instructions carefully:
- The staff/faculty member, coach, or Public Safety official who witnessed the injury or is supervising the injured student must download the following forms, which are linked below.
- S.A.I.N. (Student & Athlete Insurance Network) HIPAA Individual Authorization Form
- S.A.I.N. Accident Claim Verification Form, BOTH PAGES
- Student Accident Brochure
- The S.A.I.N forms are to be completed by the witness/supervisor, then ALL FORMS (including the Student Accident Brochure) must be emailed to student for completion.
- The student completes their portion of the forms, and emails it to: Claims@studentinsuranceusa.com
- The student must take the completed claim forms to every visit that is related to this injury or illness for billing purposes. They can be electronic versions or printed copies. If the student does not take the completed forms to every visit, they may be billed for services rendered.
- To find a clinic or provider within the network: https://www.anthem.com/ca/find-care
- Lastly, the employee who witnessed the injury or was supervising the student at the time of injury must complete the Student/Non-Student Accident Report, linked below. After completion, it must be emailed to Dawn Dittmer (Administrative Services) the same day. ddittmer@gwc.cccd.edu
For further questions, please email Veronica Arroyo (CCCD Safety, Risk, and Loss Prevention Coordinator) varroyo@cccd.edu
S.A.I.N. FORMS
STUDENT ACCIDENT BROCHURE
STUDENT/NON-STUDENT ACCIDENT REPORT
