FAMILY INSURANCE INFORMATION FORM
Note: Complete all blanks on this form. Failure to complete all blanks will result in claims processing delays.
This form must be signed and returned to Alvin Community College prior to participation in any sport.
Name of Athlete: _________________________________________________ Sport: ___________________________________
Athlete Email: ____________________________________________________ Date of Birth: ______________________________
Local Address: ___________________________________________________ Cell Phone: ______________________________
Home Address ___________________________________________________ Home Phone: ___________________________
City: __________________ State:_________ Zip:__________ Parent(s) Email: __________________________________________
EMERGENCY CONTACT INFORMATION
1. Name: _______________________________ Relationship to Athlete: ________________ Work Phone:__________________________
Email Address: _____________________________ Cell Phone:_______________________ Home Phone:_______________________
2. Name: _______________________________ Relationship to Athlete: ________________ Work Phone:__________________________
Email Address: _____________________________ Cell Phone:_______________________ Home Phone:_______________________
PRIMARY MEDICAL INSURANCE
Please complete all information – incorrect information could result in claims processing delays.
Insurance Company:___________________________________________________ Phone:______________________________________
Insurance Company Address: ________________________________________________________________________________________
Policy #:_____________________________________________________ Group #:_____________________________________________
Primary Physician Name: __________________________________________ Primary Physician Phone:_____________________________
Name of Policyholder:_____________________________________________ Relationship to Athlete:_______________________________
Policyholder Date of Birth:__________________________________________ Policyholder SS#:___________________________________
Is this plan an HMO or PPO? Yes No Is pre-authorization required to obtain treatment? Yes No
Is a second opinion required before surgery? Yes No
SECONDARY MEDICAL INSURANCE
If not applicable, please circle: NONE
Insurance Company:___________________________________________________ Phone:______________________________________
Insurance Company Address: ________________________________________________________________________________________
Policy #:_____________________________________________________ Group #:_____________________________________________
I/We authorize Alvin Community College and their designated insurance company to inspect or secure copies of case history records, laboratory reports,
diagnosis, x-rays, and any other data covering this and/or previous confinements and/or disabilities. A copy of this authorization shall be
deemed as effective and valid as the original.
I/We agree that for expenses not covered by the Alvin Community College secondary insurance policy, I will assume responsibility for.
Policy Holder Signature: ___________________________________________ Date: ______________
Student-Athlete Signature: ________________________________________ Date:______________
