Fillable EMERGENCY INFORMATION Primary Insurance Information (Please attach copy (US Air Force Civil Air Patrol)

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EMERGENCY INFORMATION Primary Insurance Information (Please attach copy (US Air Force Civil Air Patrol)

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EMERGENCY INFORMATION
(Insurance/Physician Information, Emergency Contacts, Minor Consents
Name (Last, First, Middle)
Grade
CAPID
Charter Number
Mailing Address (Number and Street)
City
State
Zip Code
(Area Code) Home Phone
(Area Code) Cell Phone
Primary Insurance Information (Please attach copy of insurance cards, front and back)
Medical Insurance Company
Co-Pay Amount
$
Prescription Coverage Company
Co-Pay Amount
$
Family Physician
Name
(Area Code) Phone
Mailing Address (Number and Street)
City
State
Zip Code
Emergency Contact (Parent, guardian or closest relative to be notified in case of emergency)
Name
Relationship to Applicant
Mailing Address (Number and Street)
City
State
Zip Code
(Area Code) Pager
(Area Code) Cell/Mobile Phone
(Area Code) Day Phone
(Area Code) Night Phone
Unit Commander Name and Grade
Unit Name
(Area Code) Unit Commander Day Phone
(Area Code) Unit Commander Night Phone
CAPF 161, JUN 13 OPR/ROUTING: HS
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EMERGENCY INFORMATION Primary Insurance Information (Please attach copy (US Air Force Civil Air Patrol)

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Completed 24 March 2022

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