Insurance Verification Form

The insurance verification form is used in varying situations. A common scenario however, is when a student gets admitted to a higher institution of learning. Universities and other institutions use these forms to verify the insurance status of their prospective students. They send out these forms to the respective insurance representatives who fill out the forms according to the current insurance status of the student in question.

Sample Insurance Verification Insurance Form

To be completed by an insurance representative

Re: ________________________            Policy number: ______________________

Student Name, Policy Number _____________________________

Dear Insurance Representative:

Please furnish us with insurance policy details of the above named student as per the current status. This is in line with his/her claim of having a policy with your company. Please confirm (yes or no against the statement) whether the said policy meets the following requirements.

(Circle one)

1. Is the aggregate cap equal to or greater than $200,000? * Yes -or- * No

2. Is repatriation equal or greater than $7,500? * Yes -or- * No

3. Is medical evacuation equal or greater than $10,000? * Yes -or- * No

4. Is the insurance acceptable in all medical facilities? * Yes -or- * No

5. Are pre-existing conditions covered after six months of enrollment? * Yes -or- * No

I hereby confirm that ___________________ does / does not meet all of the above

Requirements for the coverage period of _________________ to ________________

Name of Representative: _______________________

Signature: Date: ______________________________

Company: Phone #: ___________________________

Address: Fax #: ______________________________

Category: Verification Forms