Undergraduate Health Insurance Information Form

Fields marked with * are required.

Student's Name:

Student's Phone Number:

Student's ID Number:

Student's Email Address:

Permanent Address:

Date of Birth:

Name of Insurance Company:

Insurance Company Phone Number:

Insurance Company Address:

Policyholder's Name:

Policy Number:

Group Number:

If you do not have a group number, enter "000."

Is this plan an HMO?:

Yes
No

I have read and agree with the statement below:

All Loyola University Maryland students are required to show proof of health insurance annually. I understand that I am legally responsible for any medical expenses incurred during my enrollment at Loyola University Maryland. The University will not be responsible for any medical expenses.

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Undergraduate Health Insurance Information Form

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