Insurance Information Form
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1Name __________________________________________
University of Iowa
Student Health & Wellness
Birth Date ______________________________________
INSURANCE INFORMATION
Student ID#_____________________________________
*PLEASE INCLUDE A COPY OF THE FRONT AND BACK OF YOUR INSURANCE CARD*
I. Employer of Policyholder: _________________________________________________________________________
Primary Policyholder Information:
Name of Policyholder:
________________________________________________________________________
Address of Policyholder:
________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Phone of Policyholder:
(
) _______--__________
Birth Date of Policyholder:
______/______/__________
Self
Spouse
Partner
Father
Mother
Other
Relationship to Patient:
_________
Primary Insurance Information:
Insurance Company:
________________________________________________________________________
Address of Insurance Co:
________________________________________________________________________
Phone Number(s):
(
) _______--__________; (
) _______--__________
Policy Number:
__________________________________________________
Group Number:
__________________________________________________
**Do you have other health insurance?
___Yes ___ No If yes, please complete the following information:
II. Employer of Policyholder: ________________________________________________________________________
Secondary Policyholder Information:
Name of Policyholder:
________________________________________________________________________
Address of Policyholder:
________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Phone of Policyholder:
(
) _______--__________
Birth Date of Policyholder:
______/______/__________
Self
Spouse
Partner
Father
Mother
Other
Relationship to Patient:
_________
Secondary Insurance Information:
Insurance Company:
________________________________________________________________________
Address of Insurance Co:
________________________________________________________________________
Phone Number(s):
(
) _______--__________; (
) _______--__________
Policy Number:
__________________________________________________
Group Number:
__________________________________________________
*
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Return this form to:
Mail: University of Iowa, Student Health & Wellness
4189 Westlawn, Iowa City, IA 52242-1100
Fax: 319-335-7247
Email:
student-health@uiowa.edu
For questions visit our website at
or call 319-335-8370
S:\Forms\Business Office\Insurance Information.doc
1/08, Rev. 7/09, 11/09, 05/13, 9/13, 10/13, 5/14/15
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