Policy Holder's Home Phone: Policy Holder's Cell Phone: ... It is your responsibility to check with your insurance carri
FORM # 2A – Due by March 1, 2017
Insurance Coverage All information will be kept confidential and used solely for the purpose of providing appropriate medical care for the student–athlete. Please see next page for all instructions and information regarding insurance.
Player First Name: ________________________________________ Middle Initial: ___________ Last Name: _________________________________________ Date of Birth (MM/DD/YY): __________________ Email ___________________________________________Phone_____________________________________ Home Address: _________________________________________________________________________________________________________________________________ City: ____________________________________________________________________________________ State: ____________ Zip: ______________________________ Parent/Guardian 1 First Name: ___________________________________________ Middle Initial: _____________ Last Name: ___________________________________________ Email _______________________________________________________________________________________________Phone_____________________________________ Street Address (If different from above):______________________________________________________________________________________________________ City: ____________________________________________________________________________________ State: ____________ Zip: ______________________________ Parent/Guardian 2 First Name: ___________________________________________ Middle Initial: _____________ Last Name: ___________________________________________ Email: ________________________________________________________________________________________________ Street Address (If different from above):_____________________________________________________________________________________________________ City: ____________________________________________________________________________________ State: ____________ Zip: ______________________________ PRIMARY INSURANCE INFORMATION Policy Holder’s Name: _________________________________________ Date of Birth (MM/DD/YY): _______________________________________________ Policy Holder’s Home Phone: __________________________________ Policy Holder’s Cell Phone: _______________________________________________ Policy Holder’s Employer: ____________________________________________________________________________________________________________________ Employer’s Address: _________________________________________________ City: ____________________________ State: _____ Zip: _____________________ Insurance Company: _________________________________________ Customer Service Phone: ___________________________________________________ Ins. Comp. Claims Address: ______________________________________________________ City: ________________ State: _______ Zip: _________________ Group Number: ____________________________ ID / Member Number: ________________________ Other Number: ______________________________ Insurance Type (please circle): HMO PPO POS UNRESTRICTED
If policy is an HMO, is guest coverage available? YES NO
Primary Care Physician: ___________________________________________ Phone: _________________________________________________________________ -CONTINUED ON THE BACK OF THE PAGE-
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FORM # 2A continued – Due by March 1, 2017 SECONDARY INSURANCE INFORMATION (If Applicable) Policy Holder’s Name_________________________________________ Date of Birth________________________________________________________________ Policy Holder’s Home Phone___________________________________ Policy Holder’s Cell Phone_______________________________________________ Insurance Company__________________________________________ Customer Service Phone____________________________________________________ Insurance Company Claims Address___________________________________________________City_________________State______Zip________________ Group Number__________________________ ID / Member Number__________________ Other Number_________________________________________
Your responsibilities: All players are required to have health insurance. It is your responsibility to check with your insurance carrier to make sure that your son is covered for injuries while participating in the CHaD NH East—West High School All-Star Football Game. CONTACT YOUR INSURANCE COMPANY AND INQUIRE ABOUT ANY POLICY LIMITATIONS THAT MAY HINDER MEDICAL TREATMENT AND CARE OF YOUR CHILD WHILE AWAY FROM HOME. It is your responsibility to submit all claims for benefits due to injuries suffered related to travel, play or practice of athletics directly to your insurance company for payment. Each athlete must submit evidence of insurance coverage to CHaD before ANY participation in event activities will be allowed. The attached form and a copy of your insurance cards must be provided by March 1, 2017.
I hereby certify that the answers provided are true, complete and correct to the best of my knowledge. I understand that my son must carry an insurance policy that will remain in force and cover claims for injuries incurred while participating in any and all CHaD NH EAST-WEST HIGH SCHOOL ALL-STAR FOOTBALL GAME activities including, but not limited to group fundraising activities, individual fundraising activities, team meetings, team practices, CHaD/hospital visits, media appearances, scrimmages, the All-Star Banquet, the All-Star Game and post-game activities. I also understand that Children’s Hospital at Dartmouth-Hitchcock, Mary Hitchcock Memorial Hospital, Dartmouth-Hitchcock Clinic, Dartmouth-Hitchcock Medical Center, the event organizers, agents, affiliates, sponsors, supervisors, participants, and persons transporting the participants to and from activities related to the CHaD NH EAST-WEST HIGH SCHOOL ALL-STAR FOOTBALL GAME will not be responsible for payment of such claims. SIGNATURE OF POLICY HOLDER________________________________________________________DATE___________________________________________
PLEASE SEND THE COMPLETED FORM BY MARCH 1, 2016 USING ONE OF THE FOLLOWING MEANS: MAIL TO: CHaD Community Relations 5 Bedford Farms Drive Suite 200 Bedford, NH 03110 Attn: Tom Gauthier
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OR
FAX TO: (603) 302-1399 Attn: CHaD Community Relations
EMAIL TO:
[email protected] OR
QUESTIONS: Please send an email or call CHaD Community Relations at (603) 629-1236.
