Health Insurance Verification Form - a Place Called Home - Los Angeles, California

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Health Insurance Verification
Form
2830 South Central Avenue
Los Angeles, CA 90011
Phone 323/232-7653
www.apch.org
Fax 323/232-0139
Policy Number: ___________________________________
Medical Insurance Company: _____________________________________
Academic School Year: __________________________________________
Policy Holder Information
Policy Holder’s name (first and last): ___________________________________________
Permanent Address: ________________________________________________
City: __________________
State: ___________
Zip code: __________
Current address (if different than permanent address): ________________________________________________
City: __________________
State: ___________
Zip code: __________
Home phone number: _______________________
Mobile number: ___________________________
Work number: _______________________________
Employer’s name: __________________________________________
Employer’s address: _________________________________________
City: __________________
State: ___________
Zip code: __________
Student Information
Name (first and last): _________________________
Relationship to policy holder: _______________________
Health Insurance Verification
Form
2830 South Central Avenue
Los Angeles, CA 90011
Phone 323/232-7653
www.apch.org
Fax 323/232-0139
Policy Number: ___________________________________
Medical Insurance Company: _____________________________________
Academic School Year: __________________________________________
Policy Holder Information
Policy Holder’s name (first and last): ___________________________________________
Permanent Address: ________________________________________________
City: __________________
State: ___________
Zip code: __________
Current address (if different than permanent address): ________________________________________________
City: __________________
State: ___________
Zip code: __________
Home phone number: _______________________
Mobile number: ___________________________
Work number: _______________________________
Employer’s name: __________________________________________
Employer’s address: _________________________________________
City: __________________
State: ___________
Zip code: __________
Student Information
Name (first and last): _________________________
Relationship to policy holder: _______________________

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