Athletics

Part 2 Chadron State College Secondary Insurance Policy

Chadron State carries secondary insurance on all student-athletes, which is utilized only when your primary insurance has been expended and CSC’s deductible has been met. Please read each statement carefully. Once you have completed this section, you have the option of printing off the information. We recommend that you do so and keep it for your information.

I understand that as a student-athlete at Chadron State College, I am required to maintain primary health insurance coverage for the entire year (from the first day of practice through the last day of spring workouts) in order to qualify for the CSC secondary insurance policy.

It is my responsibility to provide the Compliance Coordinator, Melissa Miskimins, with new information or if policies or coverage changes.

I understand that if my primary health insurance coverage lapses, I am immediately ineligible for practice and competition and am responsible for any and all bills related to any injury that may occur if I am ineligible and continue to participate

I understand that Chadron State’s secondary insurance policy maintains a $5,000.00 deductible per injury that must be met by my primary insurance company or my family before any benefits will be paid by the secondary company.

I understand that all medical bills should be submitted to my primary insurance company first.

I understand that CSC’s secondary policy only covers injuries that occur during competition, practice, conditioning or any workout supervised by a coach. It does not cover non-supervised workouts/events, injuries, illness, or any injury that occurs that is not directly caused by my participation in athletics. Voluntary and/or summer workout will not be covered whether a coach is present or not.

I understand that I must consult a member of the CSC Athletic Training staff prior to seeking medical attention.

I understand that my primary insurance policy must cover major medical AND athletic injuries.

Initial to Agree to the Terms Above:

Health Insurance Information
Primary Policy
Policy Holder’s Name	Relationship to Athlete	Insurance Company
Policy Number	ID Number	Group Number
Effective Date of Policy	Expiration Date of Policy
Is this an HMO Policy?
Is this a PPO Policy?
Address for Insurance Company's Claim Office
Address	City	State
Zip Code	Phone Number	Fax Number
Secondary Policy (Optional)
Policy Holder’s Name	Relationship to Athlete	Insurance Company
Policy Number	ID Number	Group Number
Effective Date of Policy	Expiration Date of Policy
Is this an HMO Policy?
Is this a PPO Policy?
Address for Insurance Company's Claim Office
Address	City	State
Zip Code	Phone Number	Fax Number