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Austin Community College
9101 Tuscany Way
Austin, Texas 78754
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Student Accident Claim

Form Purpose: This form is from the insurance company to be used from reporting student accidents involving injury or illness.
Format: PDF (fillable and printable from this web site)
Administrative Rule and/or Procedures: All Student Accident Claims must be submitted through the Environmental Health Safety and Insurance Office.

Completed Student Accident Claim Forms must be submitted to Department Chair immediately following the incident, and then sent in to EHS and Insurance Office within 5 days of the incident. All completed forms and itemized bills must be mailed or faxed to the following:

EHS and Insurance Office
9101 Tuscany Way
Austin, Texas 78754
Fax: (512) 223-1035
Phone: (512) 223-1015

EHS Office will then submit claims to the insurance company.
Access:Available to ACC employees only (Must be viewed from within the ACC Network)

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