DEPENDENT
STUDENT CERTIFICATION
General Information
Subscriber
Name: ____________________________________ SS #:
_____________________________
Students
Name: ______________________________________ Group #:
__________________________
Relation
to Subscriber: _____________________________ Birth Date:
____________________________
Martial
Status: Single: ____Divorced: ____Separated: ____ Married:
____Date of Marriage: ___________
Employment
Status: Full-Time: _______
From: _____________________To: __________________
Part-Time:
_______ From:
______________________To: __________________
Not-
Working: ______From: ____________________To:
__________________
Working School Vacations: _______ From: _____________To: __________
OTHER COVERAGE: Is the patient covered under any
other employer group Health Insurance plan?
Yes: ________ No:
_______ IF "Yes" Please list the following:
NAME/ADDRESS
of other INSURANCE COMPANY:
__________________________________________________
_______________________________________________________________________________________________________________
____________________________________________________________________________
STUDENT STATUS
Full-Time
Student: ________________
Part-Time Student: ______________
NAME/ADDRESS
of SCHOOL:
____________________________________________________________________
___________________________________________________________________________________________
Type
of School: _____________________________
Course of
Study: ________________________
Program Length: 1 Year: ____ 2
Year: ____ 3 Year: _____ 4 Year: _____
Original
School Enrollment Date:
_____________________________________________________________
Present
School Term: From: ______________________________ To:
_______________________________
EXPECTED DATE OF GRADUATION: ________________________________________________________
NOTE: When your dependent child is no longer a full-time student, you should notify your employer through which you are enrolled. Failure to do so may result in the dependent's not being able to continue his or her protection on a direct payment basis, without a lapse in coverage.
I hereby certify the above information is correct to the best of my knowledge and authorize release of any information required with the respect to this certification.
Date: ____________ Subscriber’s Signature: ____________________________________________