The Chubb Group / Administrative Concepts, Inc. form should be completed in order to file a claim
with the insurance company to pay for a student’s medical bills after the student has had an accident.
Policy # is 9906-72-28
Policy Holder: KCTCS – College Name
Part I – Policyholder’s Report - should be completed by the student & college:
1. Claimant’s Name (injured person) – this would be the student’s name.
2. Social Security Number – not student id #
3. Gender
4. Date of Birth
5. Primary Parent E-mail – can be student’s e-mail address
6. Father’s information if applicable
7. Mother’s information – if applicable
8. Date & Time of Accident – very important
9. Place where accident occurred – name of building on college campus
10. The injured person was a: Participant (student)
11. Specify the covered class: what class was the student attending when the accident occurred
12. Dental Claims: if any teeth were damaged please list them
13. Condition of teeth before accident
14. Type of injury – indicate body part injured
15. Describe how accident occurred
16. Has the student been injured this way before?
17. Did Accident Occur? – check all that apply.
18. Name of Event or Activity – example: Welding class, while walking to class, field trip, clinical
site, etc.
19. Name of instructor
20. Signature of Business Dean or Dean of Student Affairs
21. Title of person signing the form
22. Date – don’t forget to put today’s date
Part II – Other Insurance Statement
This part should be completed by the student or their parent or legal guardian listing any other insurance
coverage they might have. Please print this information.
Certificate of No other Insurance – if the student does not have any other insurance then this part
should be signed by the student or parent/legal guardian of student.
Signature of Claimant or Authorized Representative – must be signed by the student or parent/legal
guardian of student and dated.
Mail completed form to:
Administrative Concepts, Inc.
994 Old Eagle School Road, Suite 1005
Wayne, PA 19087-1082
Please keep a copy of the form for the college and send one to Facilities Services at 300 North
Main Street, Versailles KY 40383.