Student Report of Injury

Northwest University Student Accident Reporting Steps

The Excess Accident Insurance is only for injuries sustained on campus or during off-campus NU sponsored activities.

The Wellness Center houses all Student Report of Injury original forms (formerly housed by Student Development). The Wellness Center will distribute completed copies of the form to Student Development and Security when necessary.

What to do if a student is in an accident:

Note: if the student was injured while working as a student worker, ask them to complete the employee injury report with the Human Resources Department.

Priority # 1: Care for the student (e.g., call 911 if necessary, take the student to the Wellness Center if open, administer first aid, etc.)

If the Wellness Center is open and the student does not need emergency services:

• Take the student to the Wellness Center and the staff there will complete the Student Report of Injury form with the student and any witnesses.

If the Wellness Center is closed:

• Complete Northwest University Student Report of Injury form and Northwest University Wellness Center Release of Information form (back of Injury Report form)
• Complete the Philadelphia Insurance Companies Accident Claim Form
  • University employee complete Part 1 and sign the bottom under Signature of Authorized Policyholder Representative
  • Student completes Part 2, Parent/Guardian Information, and signs the bottom of page 2 and 3 as claimant
• Make a copy of the claim form
  • Send the original Student Report of Injury and one copy of the claim form to the Wellness Center
  • Give the student the Student Insurance Accident Packet including the original claim form
• Send the student to an urgent care clinic, emergency room, or primary care physician
  • Student should present his or her primary medical insurance card along with the “Provider Information form” (last page of the Student Insurance Accident Packet)
  • Payment should proceed through the primary medical insurance provider first
• Student or guardian submits a claim
  • After the student or guardian receives the Explanation of Benefits (EOB) from the primary insurance provider copies should be mailed by the student or guardian to Philadelphia Insurance Companies.
    • NAHGA Claim Services PO Box 189, Bridgton, ME 67788
    • Or fax to 207-647-4569
    • Or email claims@nahga.com

Forms and Instructions:

• Student Report of Injury and Release of Information
• Accident Claim Packet, Instructions and Provider Information Form – note that students must contact the Wellness Center to receive the Accident Claim Form that is signed by a WC representative