For ALTERNATE HEALTH/DENTAL PROVIDER, please input the name of the insurance company you are currently covered by. DO NOT include the name of the employer your parents work for but rather the insurance company the employer works with. You may include name of Employer under “NAME OF EMPLOYER”.
PLAN MEMBER HEALTH/DENTAL NUMBER may also be referred to as “Member ID” on your insurance card. Please input your Member ID if that is what’s listed on your card.
Important Note: If your coverage includes BOTH Health and Dental from one provider, please include the same provider name, group/policy number and health/dental number for both “ALTERNATE HEALTH PROVIDER” and “ALTERNATE DENTAL PROVIDER”.