UNH ATHLETE INSURANCE VERIFICATION FORM
This form must be completed by parents prior to an athlete's participation in sports and will be kept on file in the Athletic Department in the event of a claim. This form must be completed annually due to possible changes or loss of forms. Return to: Athletic Training Dept., 145 Main St - Field House, Durham, NH, 03824.
LAST NAME _____________________ __ FIRST _________________MIDDLE INITAL STUDENT’S CELL PHONE ______________________________ DOB ________ SSN#________________ Sport(s) your son/daughter will be participating in ___________________________ GROUP MEDICAL INSURANCE COVERAGE
Is Your Son/Daughter Covered under Father’s plan? Yes No Is Your Son/Daughter Covered under Mother’s plan? Yes No
IF "NO" TO BOTH QUESTIONS ABOVE, LEAVE THE NEXT SECTION BLANK AND SIGN AT BOTTOM; IF "YES" TO EITHER QUESTION ABOVE, PLEASE COMPLETE BOTH SIDES BELOW. FATHER Name SS# Date of Birth ________________________________ Employer Work Phone Home Address Name SS# Date of Birth ________________________________ Employer Work Phone Home Address MOTHER
Home Phone
Home Phone
PLEASE COMPLETE BELOW & ATTATCH A PHOTO COPY OF BOTH SIDES OF YOUR INSURANCE CARD Name of Insurance Co. Address Name of Insurance Co. Address
Phone# Policy/ ID# Group#
Phone# Policy/ ID# Group#
Type of Plan: (Please check with your insurance carrier - this is VERY important!) FATHER MOTHER HMO (Health Maintenance Organization) HMO (Health Maintenance Organization) PPO (Preferred Provider Organization) PPO (Preferred Provider Organization) Standard(Indemnity) Medical & Hospital Coverage Standard(Indemnity) Medical & Hospital Coverage Name of Primary Care Physicians Does Your Insurance Require: A second opinion for surgery? Pre Authorization for services? Other? Phone# Yes Yes No No Fax #
I hearby certify that the answers provided are true, complete and correct to the best of my knowledge. Date Signature of Parent
ae484c71-db85-41aa-8615-80e1a2e5dd5c.doc