Health Insurance Election Notice

Student Name
Student ID
Parent (Policy Holder)
Policy Holder's Date of Birth 
Street Address
City
State
Zip
Country
Phone
E-mail address
 
For 2013-14, student is covered under family policy:
Insurance Company:
Street Address
City
State
Zip
Insurance Co. Phone
Policy Number

Student requests Hartwick College insurance coverage for:
 Coverage Jan 1 to Aug 24, 2014, for $810
Decline all coverage