United Healthcare Student Verification Form
It is necessary for all students to have health insurance and so United Healthcare student verification form is the insurance form that the students need to fill up to get health insurance. This form helps students to get extra insurance benefits from United Healthcare when needed.
Sample United Healthcare Student Verification Form:
Personal details of the student:
Name: First name ___________ Middle name __________ Surname _____________
Father’s name: First name __________ Middle name _________ Surname __________
Address: Street address ____________ City name ____________ State _____________ Zip code _____________
Home contact number: _____________ Mobile number: _______________
Educational institution details:
(To be filled by registrar)
Name of school or university: _________________
Address: _____________________________
Telephone number: ________________
Course enrolled for: __________________
Date of enrolment: ______________
Date of completion of course: ________________
I assure that the above mentioned student is a full time student of our institution.
_____________________
Signature of the registrar
Dated: ____________
Category: Verification Forms
