No Insurance

I, (Student-athlete name) , understand that Minnesota State University Mankato carries a blanket Accidental Death and Accident Bodily Injury Policy on all student athletes participating in intercollegiate athletics at Minnesota State University Mankato I further understand that this insurance policy carries a deductible of $250.00 per injury. In consideration of my being allowed to participate as a member of an intercollegiate team, I understand that I am responsible to pay the first $250.00 of medical services afforded to me by a medical provider per injury prior to coordination of benefits by Minnesota State University Mankato.

I understand that if I fail to pay $250.00 deductible per injury, I will be held responsible for the full cost of medical services afforded me by the medical provider. I also understand that failure to pay may result in my account being turned over to collection to attain payment. I further understand that failure to pay may result in immediate removal from the team. I hereby give my permission for the medical provider to share information regarding the status of my financial account with Minnesota State University Mankato head athletic trainer.

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