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 2014-15, 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:
12-Month Coverage for $1520
Decline all coverage