Incident Insurance Report

Incident Report Form
  • Employee/Administrator witnessing, reporting an accident completes this form.
  • Employee/Property-Send report to Adminstrative Services Executive Director
  • Visitors/Student-Send report to Laura Leatherwood 565-4220 or Debbie Carpenter in Student Center (828) 627-4503

Student Accident Insurance Coverage

Insurance Form
  • Student will need to complete Insurance form
  • Bring to Student Services for Insurance Administrator signature
  • Student will need to send claim to Summit America to the address on the instruction page.

Debbie Carpenter,
Student Development Services
(828) 627-4502
Haywood Community College
185 Freedlander Dr.
Clyde, NC 28721

How To File A Claim

If a claim arises, obtain a claim form for the school within 30 days of the date of loss or as soon as reasonably possible. Proof of loss must be furnished within 90 days for the date of the accident. Complete the form; bring to Student Services to be signed by College Insurance representative; attach all medical bills; primary explanation of benefits and mail to the insurance carrier.

If other medical insurance is in force at the time of the claim, no benefits are payable for any expense that is payable by other insurance.

2010-2011 Student Accident Insurance Plan Brochure

This page was last modified on Wednesday, June 08, 2011 at 09:37 AM