Hartwick-Health Insurance Election Notice

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HEALTH INSURANCE ELECTION NOTICE

Health Insurance Election Notice

Student Name
Student ID
Parent (Policy Holder)
Street Address
City
State
Zip
E-mail address

For 2011-12, student is covered under family policy:
Insurance Company:
Street Address
City
State
Zip
Policy Number

Student requests Hartwick College insurance coverage for:
January-August coverage for $570
Add $285 to increase coverage to $50,000 per incident (optional)
Decline all coverage