DMVA Form 83-3 "Notification to Insurer of Re-enrollment as Full-Time Student" - Pennsylvania

What Is DMVA Form 83-3?

This is a legal form that was released by the Pennsylvania Department of Military and Veterans Affairs - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2011;
  • The latest edition provided by the Pennsylvania Department of Military and Veterans Affairs;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DMVA Form 83-3 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Military and Veterans Affairs.

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Download DMVA Form 83-3 "Notification to Insurer of Re-enrollment as Full-Time Student" - Pennsylvania

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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
NOTIFICATION TO INSURER OF RE-ENROLLMENT AS FULL-TIME STUDENT
An amendment to 51 Pa.C.S. § 7309, effective 21 February 2006, provides for extension of health insurance
coverage in certain circumstances. To qualify for this extension you must:
Be a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the
United States
Be ordered to active federal duty or state active duty (other than active duty for training) for 30 or more
consecutive days
Be a full-time student (15 or more credit hours or equivalent) at an approved institution of higher learning.
Be eligible for coverage under your parents’ health insurance program at the time you are ordered to
active duty.
Become ineligible because of your age for coverage under your parents’ health insurance program after
you become a full-time student at any time after your active duty tour.
Re-enroll as a full-time student for the first term or semester beginning 60 or more days after your release
from active duty.
If you meet these eligibility criteria, you may qualify to extend your coverage under your parents’ health
insurance program while you are a full-time student for a period equal to your active duty tour. To qualify you
must submit three forms to your parents’ insurer:
Notification to Insurer of Placement of Active Duty (DMVA Form 83-1)
Notification to Insurer of Completion of Active Duty (DMVA Form 83-2)
Notification to Insurer of Re-Enrollment as Full-Time Student (DMVA Form 83- 3; this form)
Please complete this form and submit it to the provider of your family’s health insurance coverage under which
you are or have been covered:
Name of Military Member: ___________________________
Phone Number:(___) ______________
Address of Military Member
_________________________________________________________
Birth Date of Military Member:
_________________
Age of Military Member: _____________
Unit of Assignment of Military Member: _______________________________________
Start Date of Active Duty:
________________
End Date of Active Duty:__________
Name of Institution of Higher Learning: ____________________________________________
Date of Re-enrollment as of Full-Time Student:_________________________________________
Name of Policy Holder (Parent): ______________________
Phone Number: (____) _____________
Address of Policy Holder (Parent):
____________________________________________
____________________________________________
Name and Address of Insurer:
___________________________________________________
(Provider of Health Care Coverage
___________________________________________________
Insurer Policy or Group Number:
___________________________________________________
I hereby notify the health care insurance provider of my parent that I am an eligible member of the Pennsylvania
National Guard or a Reserve Component of the Armed Forces of the United States and that I have re-enrolled
as a full-time student for the first term or semester beginning 60 or more days after my release from active duty.
____________________________
_______________________________________
Date
Signature
DMVA FORM 83-3 (FEB 11)
Mail this form to your parent’s health care insurance company.
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
NOTIFICATION TO INSURER OF RE-ENROLLMENT AS FULL-TIME STUDENT
An amendment to 51 Pa.C.S. § 7309, effective 21 February 2006, provides for extension of health insurance
coverage in certain circumstances. To qualify for this extension you must:
Be a member of the Pennsylvania National Guard or a Reserve Component of the Armed Forces of the
United States
Be ordered to active federal duty or state active duty (other than active duty for training) for 30 or more
consecutive days
Be a full-time student (15 or more credit hours or equivalent) at an approved institution of higher learning.
Be eligible for coverage under your parents’ health insurance program at the time you are ordered to
active duty.
Become ineligible because of your age for coverage under your parents’ health insurance program after
you become a full-time student at any time after your active duty tour.
Re-enroll as a full-time student for the first term or semester beginning 60 or more days after your release
from active duty.
If you meet these eligibility criteria, you may qualify to extend your coverage under your parents’ health
insurance program while you are a full-time student for a period equal to your active duty tour. To qualify you
must submit three forms to your parents’ insurer:
Notification to Insurer of Placement of Active Duty (DMVA Form 83-1)
Notification to Insurer of Completion of Active Duty (DMVA Form 83-2)
Notification to Insurer of Re-Enrollment as Full-Time Student (DMVA Form 83- 3; this form)
Please complete this form and submit it to the provider of your family’s health insurance coverage under which
you are or have been covered:
Name of Military Member: ___________________________
Phone Number:(___) ______________
Address of Military Member
_________________________________________________________
Birth Date of Military Member:
_________________
Age of Military Member: _____________
Unit of Assignment of Military Member: _______________________________________
Start Date of Active Duty:
________________
End Date of Active Duty:__________
Name of Institution of Higher Learning: ____________________________________________
Date of Re-enrollment as of Full-Time Student:_________________________________________
Name of Policy Holder (Parent): ______________________
Phone Number: (____) _____________
Address of Policy Holder (Parent):
____________________________________________
____________________________________________
Name and Address of Insurer:
___________________________________________________
(Provider of Health Care Coverage
___________________________________________________
Insurer Policy or Group Number:
___________________________________________________
I hereby notify the health care insurance provider of my parent that I am an eligible member of the Pennsylvania
National Guard or a Reserve Component of the Armed Forces of the United States and that I have re-enrolled
as a full-time student for the first term or semester beginning 60 or more days after my release from active duty.
____________________________
_______________________________________
Date
Signature
DMVA FORM 83-3 (FEB 11)
Mail this form to your parent’s health care insurance company.