Online Health Insurance Card/Information Submission Form

Online Health Insurance Card/Information Submission Form
Thank you for attending our upcoming/recent Student Health & Wellness Center (SHWC) event and protecting the herd!

Please complete the form below and upload the front/back of your health insurance card.
Full Name*

First (Given) Last (Family)
I am a studentI am an employeeOther
Student U# (if applicable)
Birth Date*

MonthDayYear
Email Address*

Confirmation Email
Cell/Mobile #*
Question(s)
YesNo
Upload Insurance Card (front/back)

Browse Files

Cancelof
Insurance Company Name
Insurance Company Claims Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Company Phone Number
Member ID/Policy #
Member Group ID #
Insurance Type
Insurance Policy Holder’s Name

First NameLast Name
Relationship to Policy Holder’s
Policy Holder Date of Birth

MonthDayYear
Insurance Policy Holder’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Insurance Policy Holder’s Phone Number
Yes, I am an existing patient.No, I am a new patient.
Please select which event you attended/will attend
Should be Empty: