Health Insurance Form

Please complete the following information:

Student Name:

Student's Social Security Number:

Birth date
(month/day/year)

/ /

College Box Number:

Student's ID Number:

Phone Number:

Please check one of the following and complete the appropriate information:

I have health insurance and do not wish to be billed for the Security Mutual Insurance Company Plan. The following is my health insurance information.

	Policy Holder's Name:
	Insurance Company Name:
	Group Policy Number:

I do not have health insurance coverage, therefore, I will participate in the Security Mutual Insurance COmplany Plan offered by Geneva College. The 2008-2009 rate is $308.00

I attest that the information I have provided is accurate. I acknowledge that it is my responsibility to report any change of personal insurance information to the Business Office for my records. I understand that the Security Mutual Life Health Insurance Policy, if purchased, is for the period August 1, 2008 - August 1, 2009 and cannot be canceled after the change deadline regardless of my student status.

Please sign this form by typing your name and typing the date in the spaces provided below. Your signature validates this form and indicates that you have completed the information and that the information is true.

Student Signature

Date: