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If you already have health/accident/hospitalization coverage Complete Section I to provide proof of insurance. Proof of Health Insurance Form SPRING 2014 All full-time Cairn University students must be covered by a health/accident/hospitalization insurance policy and provide proof of coverage to the Business Services Office. This means you are already covered by a parent/guardian s or your own policy. If you DO NOT have health/accident/hospitalization coverage Please complete and return this form by January 1. Failure to do so will result in your automatic enrollment into the University s health insurance plan and a charge to your student account. Once this coverage is issued by the insurance company it cannot be canceled* No premium refunds will be granted* Student Name SECTION I Soc* Sec* No* Student ID Name of Insurance Company Address of Insurance Company Policy Number Certificate Number Group Number Code Number Other Policy Identifying Number s Relationship to Student e*g* Father Expiration Date or terms regarding when coverage will cease e*g* when student turns 21 I hereby certify that the above information is complete and accurate to the best of my knowledge. I understand that if any of this information is to change I must notify the Student Accounts Office. Student s Signature Date Health Coverage Needed Cairn University s student insurance plan* I agree to pay the insurance premium* The premium will be 790. 00 for a 7-month period of coverage which begins January 1st. For internal use only Date received MM/DD/YYYY / / 200 Manor Avenue Langhorne PA 19047 2990 215. This means you are already covered by a parent/guardian s or your own policy. If you DO NOT have health/accident/hospitalization coverage Please complete and return this form by January 1. Failure to do so will result in your automatic enrollment into the University s health insurance plan and a charge to your student account. Failure to do so will result in your automatic enrollment into the University s health insurance plan and a charge to your student account. Once this coverage is issued by the insurance company it cannot be canceled* No premium refunds will be granted* Student Name SECTION I Soc* Sec* No* Student ID Name of Insurance Company Address of Insurance Company Policy Number Certificate Number Group Number Code Number Other Policy Identifying Number s Relationship to Student e*g* Father Expiration Date or terms regarding when coverage will cease e*g* when student turns 21 I hereby certify that the above information is complete and accurate to the best of my knowledge. Once this coverage is issued by the insurance company it cannot be canceled* No premium refunds will be granted* Student Name SECTION I Soc* Sec* No* Student ID Name of Insurance Company Address of Insurance Company Policy Number Certificate Number Group Number Code Number Other Policy Identifying Number s Relationship to Student e*g* Father Expiration Date or terms regarding when coverage will cease e*g* when student turns 21 I hereby certify that the above information is complete and accurate to the best of my knowledge. I understand that if any of this information is to change I must notify the Student Accounts Office.

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