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Athletic Training Department  ♦ 101 College Heights♦ Cisco, Tx 76437 ♦ 254-442-5195

Athletic Insurance Questionnaire


Student Information
Student Name

Social Security Number
do not enter dashes

Date of Birth
do not enter dashes
 
Age
 
 
Home (Mailing Address)
Street
City
  State 
  Zip 

Father/Guardian Information
Name

Phone
 
SS #

Address

City
 
State
Zip

Employer
 
Phone


Insurance Information
Please complete all that apply.    Put N/A in fields that do not apply.


Insurance Carrier

Policy Number

Group Number

ID Number

Phone Number

Mother/Guardian Information
Name

Phone
 
SS #

Address

City
 
State
Zip

Employer
 
Phone


Insurance Information
Please complete all that apply.    Put N/A in fields that do not apply.


Insurance Carrier

Policy Number

Group Number

ID Number

Phone Number


Do you have medical insurance coverage, and your son/daughter is not covered or is partially covered due to limitations?


If your son/daughter had medical insurance coverage as an eligible dependent from your previous marriage, as mandated in a divorce decree, please give them details for filing a claim:

I/we the undersigned understand fraudulent claim submission: Any incorrect, misleading or undisclosed information, and any attempt to collect full primary benefits in excess of the total covered expenses under two or more group insurance plans is considered mail fraud and will fail under federal jurisdiction.


Any person who knowingly and with intent to defraud, files a statement of claim containing materially false information or conceal information concerning any material fact, commits a fraudulent insurance act, which is a crime.



I , Father/Guardian, agree that all information provided in this document is accurate and complete to the best of my knowledge.    Date  


I, Mother/Guardian, agree that all information provided in this document is accurate and complete to the best of my knowledge.     Date