[Insert date]
[Covered individual’s full name]
[Covered individual’s]
[City], [State] [Zip code]
[Mr./Ms.] [Last name]:
This letter is to serve as confirmation that [insert policyholder’s name] has an active health
insurance policy in place with [insert name of insurance company]. This is [choose one) [an
individual plan] [a group plan provided through (specify name of employer through which the group
plan is offered)].
The policy number is [insert policy] and the effective date is [insert effective date]. The policy is
issued to [specify the name of the insured]. The following dependents of the policyholder are
covered under this policy:
• [First and last name of covered dependent]
• [First and last name of covered dependent]
• [First and last name of covered dependent]
My signature on this letter certifies that the above information is true and correct as of the date of
this letter. If you require any additional information, please contact me at [insert email address] or
[insert phone number, with extension if applicable].
Regards,
[Signature]
[Typed name of authorized insurance company representative]
[Job title]
