Insurance Provider

Enter the full name of the health insurance provider. This field is required.

Address

Enter the provider's mailing address. There are two fields available for this address.

City

Enter the name of the city.

State

Select the State.

Zip

Enter the zip+four code.

Policy number

Enter the policy number. This s provided by the employer. This number should appear on the person's insurance card.

Policy holder

Select the name of the person in the case who is named as the holder of the policy. The holder should appear on the person's insurance card.

Group Policy/Individual Policy

Select the radio button next to the type of policy. A group policy is one provided by the person's employer or by another organization. An individual policy is one the person has purchased.

Group #

Enter the group number, which should appear on the insurance card.

Policy Begin Date

Enter the date on which the insurance coverage began. Use the format MM/DD/YYYY.

Policy End Date

Enter the date on which the insurance covered ended. Use the format MM/DD/YYYY.

Coverage Through Employment?

Select Yes or No to indicate whether the insurance policy is provided by the person's employer. This field is required.

Employer

If you selected yes in the field above, select the name of the employer. This list displays the employer records of the policy holder selected on this screen.