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000298712 / KAMV0000018057103STUDENT OR ATHLETE ACCIDENT CLAIM FORM Excess Coverage K12 ACCOUNTS CLAIMS DEPARTMENT 1712 Magnavox Way, P.O. Box 2338 | Fort Wayne, IN 468012338 Ph: 8002372917 Fax: 3123819077
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01
Gather all necessary information about the student involved in the accident.
02
Document the date, time, and location of the accident.
03
Include a detailed description of what occurred during the accident.
04
Collect information from witnesses, if available, including names and contact details.
05
Fill out the form with any medical attention received by the student.
06
Ensure all signatures required on the form are obtained, including that of a guardian if applicable.
07
Submit the completed form to the appropriate school authority.

Who needs k12 student accident?

01
Students enrolled in K12 education who experience an accident during school hours or school-sponsored activities.
02
Parents or guardians of K12 students who want to report accidents for insurance purposes or for record-keeping.
03
School administrators and staff responsible for student safety and incident documentation.
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A K12 student accident refers to an incident involving a student enrolled in kindergarten through 12th grade that results in injury or harm while on school premises or during school-sponsored activities.
Typically, the school officials or administrators are required to file a K12 student accident report, although parents or guardians may also need to be involved in the process.
Filling out a K12 student accident report generally involves providing details about the incident, including the date, time, location, a description of what happened, the extent of the injuries, and any witnesses.
The purpose of filing a K12 student accident report is to document incidents for legal and insurance purposes, ensure proper follow-up care for the student, and help improve safety protocols within the school.
Information that must be reported includes the student's name, date of birth, the date and time of the accident, details about the incident, any injuries sustained, and the names of any witnesses.
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