Student-Athlete Health Insurance Questionaire

Please print all 2 pages of the form, fill out completely and fax to (518) 783-2992 or mail to:

 

Name: ______________________________________________ Sport(s): ________________________________________

Social Security Number: ______________________________________ Date of Birth: ______________________________

Campus Address: _____________________________________________________________________________________

Campus Phone # ___________________________________     Home Phone # ___________________________________

Home Address: _______________________________________________________________________________________

Person(s) to contact in an emergency: ____________________________________________________________________

Home Phone # ____________________________________     Work Phone # ____________________________________

Information About Your Parents

Father's Name: ___________________________________________   Home Phone: _______________________________

Home Address: _______________________________________________________________________________________

Social Security Number: ____________________ Date of Birth: _______________ Occupation: ______________________

Employer's Name and Address: __________________________________________________________________________

_____________________________________________________________________________________________________

Work Phone: _______________________________     Pager Number: _______________________________

Insurance Information

Do you have an insurance company plan to cover the student-athlete?   Yes   or   No

Name and Address of the company:  ______________________________________________________________________

_____________________________________________________________________________________________________

Company Phone Number: _______________________________       Policy Number: _______________________________

Identification Number: ________________________________       Group Number: _________________________________

 

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