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Form must accompany the Academic HealthPlans enrollment form. Student Name (Last, First, MI) Social Security Number School Name Policy Number List Dependents to be Insured below DOB MM/DD/YYYY Sex SSN Spouse (Last, First, MI) M F / / - - Child (Last, First, MI) M F / / - - Child (Last, First, MI) M F / / - - Qualifying Event Date Student Signature Date Signed Qualify.

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