Dependent Student Certification Form - Healthplex

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DEPENDENT STUDENT
Certification Form
Section one: To be Completed by Subscriber
PLEASE NOTE: You must submit full-time student status EVERY semester in order for your dependent’s coverage to remain in effect.
Subscriber’s Group Number
Subscriber’s Social Security / I.D. Number
Subscriber’s Name
Subscriber’s Address
City
State
Zip Code
Student’s Name
Student’s D.O.B.
Name of School
Address of School
City
State
Zip Code
Semester:
Fall
Winter
Spring
Summer
Mo./Yr.
Mo./Yr.
Mo./Yr.
Mo./Yr.
/
/
/
/
Year of
1
2
3
4
5+
Has student served in the Armed Forces?
If “Yes” , from
Study
Yes
No
when:
Definition of a Dependent Student:
A full-time student is a person who meets all of the following conditions:
(a) He/she is at least 19 years of age; (b) unmarried; (c) receives at least half of his/her support from the employee or member; and
(d) is enrolled full-time in an accredited secondary or preparatory school or college.
I certify that my dependent, ____________________________, meets all of the requirements for eligibility as a dependent student.
A. 19 years of age or older:
Yes
No
B. Unmarried:
Yes
No
Yes
No
C.
Received at least half of his/her support from employee or retired employee:
Yes
No
D. Is the full-time student in an accredited secondary, preparatory school or college:
E. Expected date of graduation:
Month:
Year:____________
I agree to advise Healthplex promptly of any changes in my child’s dependent status.
Subscriber’s Signature
Date
Section Two: To be Completed by Authorized Person in the Registrar’s Office of the
Educational Institution
The student named in this form may be eligible for dental coverage under his/her parent’s dental insurance plan. See section one (above) for
definition of dependent student. In order for Healthplex to determine a student’s eligibility, please complete the following information:
Please mail, fax or email this
1. Is the student enrolled full-time?
Yes
No
Affix Institution Seal/Stamp Here
completed form to:
2. Student’s program of study:
Healthplex, Inc.
3. Student’s expected degree or
diploma:
Attn: Enrollments Department
333 Earle Ovington Blvd., Suite 300
4. Is your institution accredited?
Yes
No
Uniondale, NY 11553-3608
5. Registrar’s Telephone Number:
F
516 227 0582
6. Authorized Signature/Title:
E
Any person who knowingly and with intent to defraud any insurance company or other person files a statement containing any materially false
information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
which is a crime.
*A copy of this form can be obtained at
F-2290
Print 06/16

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