P.O. BOX 809067
DALLAS, TEXAS 75380-9067
NOTICE: Anyone who knowingly misrepresents or falsifies essential information requested
by this form may, upon conviction, be subject to fine or imprisonment.
-PLEASE PRINT ALL INFORMATION-
PART I - MUST BE COMPLETED BY STUDENT AND SIGNED
Name of College or University, City and State
Student ID Number
Insured Student’s Name
LAST NAME FIRST NAME M.I. SOCIAL SECURITY # PHONE #
❑ Present Address
❑ Home Address
PLEASE MAIL ALL CORRESPONDENCE AND PAYMENTS TO THE ADDRESS ABOVE.
If claim for dependent, give dependent’s name
Relationship to Insured
1. Date of accident or sickness.
Date of first treatment
2. Indicate reason for medical treatment.
If injury, describe how and when accident
occurred and indicate if work related.
4. If injured in play or practice of sport,
indicate which sport.
5. Have you previously been troubled
with this condition?
❑ No Date
6. Were you seen or referred by the
physician for this condition?
❑ No Date
7. Name and address of Provider,
other than Student Health Service.
8. Give names of all other physicians
9. Hospitalized? If so where and what dates.
PAYMENT WILL BE MADE TO THE PROVIDERS OF SERVICE, UNLESS A PAID RECEIPT IS ATTACHED AT TIME OF SUBMISSION.
To any medical care provider, medical care facility, insurer, government-sponsored health plan, or employer: I authorize the release of any medical information about me
to Student Insurance. This applies to all information about the diagnosis, treatment, or prognosis of any illness or injury I now have or have had in the past. The Company