Student Health Plan Coordination of Benefits Form
Student Information
Name
Student ID
Date of Birth
Phone Number
Mailing Address
Other Health Insurance Information
Policyholder Name
Relationship to Student
Self
Spouse
Parent
Other
Insurance Company Name
Policy Number / ID
Group Number
Effective Date
Insurance Company Address
Insurance Company Phone Number
Additional Information
Is this other insurance your primary coverage?
Yes
No
Type of Coverage
Medical
Dental
Vision
Other
Additional Comments or Information
Signature
Date