Medical Insurance Questionnaire

Medical Insurance Information Form
Please fill out the following to help us provide you with medical insurance coverage:
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Social Security #
Do you have medical insurance:*

YesNo
If "yes" please provide name of insurance
Copy of your Medical Insurance Card

Cancelof
All our Diocesan Seminarians MUST have medical insurance coverage. If you don’t have medical insurance, one will be provided to you by the Diocese. The Diocese pays 75% of it and the remaining 25% is paid by you through your student loan. If you are covered through your own or your family’s insurance the Diocese will pay only up to the 75% that it pays for the insurance provided by the Diocese. Once you are ordained a Deacon the Diocese pays for 100% of it.
I swear under penalty of perjury the above to be true and correct.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

Medical Insurance Information Form