Ferrum College Student Athlete Insurance Ferrum College Athletic Department is secondary after athletes insurance Contact David Jager

Ferrum College
Student Athlete Insurance

Ferrum College Athletic Department is secondary after athletes insurance Contact Tom Cosgrove540-365-4477

SPORT		DATE CREATED/UPDATED
ATHLETE
	Last Name	First Name	Middle Initial

HOME ADDRESS
CITY STATE ZIP
HOME PHONE
CAMPUS PHONE
CELL PHONE
BIRTH DATE
GENDER	Male Female
FC STUDENT ID
EMAIL ADDRESS

FATHER
	Last Name	First Name	Middle Initial

ADDRESS
CITY STATE ZIP
HOME PHONE
WORK PHONE
EMPLOYER
WORK ADDRESS
EMAIL ADDRESS

MOTHER
	Last Name	First Name	Middle Initial

ADDRESS
CITY STATE ZIP
HOME PHONE
WORK PHONE
EMPLOYER
WORK ADDRESS
EMAIL ADDRESS

INSURANCE INFORMATION
I am not a member of any Health Insurance Plan
I am a member of Ferrum Student Health insurance (Commercial Traveler's Mutual Insurance, Policy 07J1A15)*
I am a participating family member of the following Primary Health Insurance Plan

SUBSCRIBER

Last Name

First Name

Middle Initial

INSURANCE TYPE

HMO	Tri Care	Foreign	OTHER
PPO	Champus	Traditional	POS

COMPANY
PHONE
ADDRESS
POLICY NUMBER
GROUP NUMBER
PRE CERT PHONE NUMBER
NOTES
DOES THIS POLICY REQUIRE PREAUTHORIZATION FOR CARE? Yes No If yes, please supply: Primary Care Physician Name: Primary Care Physician Phone:

OTHER INSURANCE

SUBSCRIBER

Last Name First Name Middle Initial

INSURANCE TYPE

COMPANY

PHONE

ADDRESS

POLICY NUMBER

GROUP NUMBER

PRE CERT PHONE NUMBER

NOTES

DOES THIS POLICY REQUIRE PREAUTHORIZATION FOR CARE? Yes No
If yes, please supply:
Primary Care Physician Name:
Primary Care Physician Phone:

* Ferrum Student Health Insurance Plan provides coverage for illness and non athletic related injury, it does NOT provide coverage for an injury sustained while participating in a Ferrum Athletic Dept. Sponsored Game or Practice.