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PART B: ATTENDING Physicians STATEMENT Health Care Provider will complete and return copy and all applicable billings to: SOUTHERN ILLINOIS UNIVERSITY UNIVERSITY RISK MANAGEMENT MAILCODE 6829 CARBONDALE, IL 62901 PHONE: 618/536-2101 FAX: 618/453-5442 PART A: PARTICIPANT DATA Name of Covered Program/Camp: Sponsoring SIU Department: Location: Name of Claimant: Male FemaleDate of Birth of Claimant: Name of Parent if Claimant is a Minor: Street:City:State: Zip Code: Telephone: Primary Insurance Policy Information (Name, ID#, Group#, Phone# and address):Program Opening Date: Program Closing Date: Name & Phone Number of Department Contact: Date and Hour of Accident or Sickness: Nature of Injury or Sickness: How and Where did Accident Occur? (Accident Claims Only): Was Claimant in a University-Sponsored Program Activity at the Time of Incident? 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