Name
Michigan Catholic Conference
Phone
(800) 395-5565
Fax
(517) 372-3940
Address
510 S. Capitol Ave.
Lansing, MI 48933

Student Accident / Injury Reporting Forms Flow Chart

Student Accident Report

  • Complete for all injuries requiring medical attention other than minor cuts or bruises
  • Completed by supervising staff member
  • Copy for your accident files
  • Forward original to Gallagher Bassett Services office
  • This protects you and your (Arch) Diocese for potential liability/negligence claims

Student Assurance Services Claim Form

  • Student accident medical policy provided by your (Arch) Diocese
  • Covers out of pocket medical costs1 for injuries occurring during school sessions and school-sponsored activities
  • Parent/guardian will request claim form to cover expenses
  • Complete Part A from information contained in your copy of the Student Accident Report
  • Provide claim form to parent/guardian
  • Parent/guardian pursues claim with Student Assurance Services

As always, If you have any questions or concerns, please do not hesitate to call the Risk Management Department at (517) 372-9310 or 1-800-395-5565.

  1. Subject to terms and conditions of policy
Name
Michigan Catholic Conference
Phone
(800) 395-5565
Fax
(517) 372-3940
Email
Address
510 South Capitol Avenue
Lansing, Michigan 48933
Multiple People Add Symbol Arrow Pointing Upward Two Arrows Forming a Circle Federal Building Chat Bubble Catholic Church Clipboard and Checkmark Clipboard and Plus Sign Office Building Envelope Person's Face Paper Document Flag Waving Lightning Bolt Person Raising Their Hand Key Hamburger Menu Icon Newspaper Clipping Graduation Cap Magnifying Glass Dollar Sign Five-Point Star Speech Bubbles