Eureka College New Student Packet 2013-14 | Page 17

Date: _____________________________ Name: _____________________________________________________ Sport (if athlete): ____________________ Date of Birth: _____________________________ Home Address:___________________________________________ Home Phone: ( ______ ) _______ - ________ City: _________________________________________________________ State: ___________ ZIP: ___________ Parent Information (Required if student is covered under a parent’s policy. Athletes must complete information for both parents for secondary insurance processing.) Father/Guardian MOTHER/GUARDIAN Father’s Name:____________________________ Mother’s Name:___________________________ Address:_________________________________ Address:_________________________________ ________________________________________ ________________________________________ Employer________________________________ Employer________________________________ Address:_________________________________ Address:_________________________________ _______________________________________ _______________________________________ Telephone: ( ______ ) _______ - __________ Telephone: ( ______ ) _______ - __________ Medical Insurance Medical Insurance Company or Plan:_________________________ Company or Plan:_________________________ Address:_________________________________ Address:_________________________________ _______________________________________ _______________________________________ Policy Number: ___________________________ Policy Number: ___________________________ Telephone: ( _____ ) ______ - ___________ Is this plan an HMO or PPO? Yes No Is pre-authorization required Yes No to obtain treatment? Is a second opinion required Yes No before surgery? insuranceverification (This side of the form is required of ALL Eureka College students.) Telephone: ( _____ ) ______ - ___________ Is this plan an HMO or PPO? Yes No Is pre-authorization required Yes No to obtain treatment? Is a second opinion required Yes No before surgery? Student Information If you are not on your parent’s insurance policy, enter either your personal insurance information or write “Eureka College Insurance” (if purchasing College insurance). Medical Insurance Company or Plan: ________________________________________________________________ Address: ____________________________________  Is pre-authorization required to obtain treatment? City/State/Zip:_______________________________ Is a second opinion required before surgery? Yes Policy Number: ______________________________ Is this plan an HMO or PPO? Yes No Yes No No Telephone: ( _____ ) ______ - ___________ 17