Form Gg015024-Pa - Dependent Eligibility Certification
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1Dependent Eligibility Certification Form
General Information
Member Name:
Individual Plan #:
Dependent Name:
Dependent Date of Birth:
Member Address:
Member ID#:
Student Certification
1. Is the dependent a full-time student at an accredited public or private institution of higher education?
YES
NO
2. Name of school in which dependent is enrolled: _____________________________________________________
3. Address of school: ____________________________________________________________________________
4. Telephone # of school: _________________________
5. Expected date of graduation (if this year): ___/___/___
mm / dd / yy
6.
Student ID#: ________________________________
Disability Certification
1. Is dependent now incapable of self –support because of a disability?
YES
NO
2.
Age of dependent when disability occurred:
______
3. Nature of disability (Please provide as much detail as possible):
___________________________________________________________________________________________
___________________________________________________________________________________________
4. Prognosis (estimate months or years): ____________________________________________________________
5.
Name and address of Primary Care Physician: _____________________________________________________
_____________________________________________________
_____________________________________________________
I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND AUTHORIZE
RELEASE OF ANY INFORMATION REQUEST IN REGARD TO THE CERTIFICATION.
_________________________________________________________
_______________________________________
Member Signature
Date Signed
Any person who includes any false or misleading information on an application for insurance commits a fraudulent insurance act and is
subject to criminal and civil penalties.
Please complete this form and return it in the envelope provided to the following:
The Guardian Life Insurance Company of America, P.O. Box 254888 Sacramento, CA 95865
GG015024-PA
(6/16)
The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004.
GUARDIAN® and the GUARDIAN G® logo are registered service marks of The Guardian Life Insurance Company of America and are used with express permission.
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Parent category: Business