ࡱ> 574 bjbj΀ 4)))))==== I=]]]]]888$)88))]] )])]J]8B!%=) 0,C3CJC)J<8"Zr888-888C888888888 : INSURANCE VERIFICATION FORM PLEASE PRINT: ____________________ _______________________ __________________ Last Name First Name Middle Name ____________________ _______________________ __________________ Student I.D. Number Telephone Number E-mail address College at UTHSC Program and Year I HEREBY ATTEST TO THE FOLLOWING: *I DO NOT wish to enroll in the UT Health Science Center Health Insurance plan. *I currently possess equivalent health insurance to that which is provided in the UT Health Science Center plan. *I understand that I am required to have equivalent health insurance throughout my complete student career at the UT Health Science Center. *I understand that to falsify this information is a violation of the Honor Code and of The Ethical and Professional Behavior expected of the UT Health Science Center students and that falsification of the information may result in appropriate disciplinary actions. *I understand that my enrollment in an equivalent plan is required by the end of the first week of classes, which I attend at the UT Health Science Center. *This waiver must be filed annually during the Summer/Fall term of the UTHSC. *I understand that I am responsible for all financial liabilities associated with my health care. __________________________________ ______________________ Signature Date Please provide the name of the insurance company. (PLEASE PRINT) _____________________________ _____________________________ ATTACH A COPY OF YOUR PROOF OF INSURANCE (such as a photocopy of your insurance card). MAIL TO: Office of Student Life Phone: 901-448-4860 800 Madison Avenue, Suite 300 Fax: 901-448-7585 Memphis, TN 38163 E-mail: lroemer@uthsc.edu )@An     0 1 2 R U X ^  ] g ~ K P h )0DHJKżŵůŵũũh# hHCJ h9c5\ h95\ h! KCJ h9CJ hH>*CJhH5CJ\ hHCJ h9ch9c h ;~>* hi^>*hi^ h9c>*h9ch! Kh ;~h hH5\hH9+,n   1 2 T U   K  ~ @ &Pgd ;~ @ Pgd ;~ ~ @ PgdK L : O P ()b21F:p9/ =!"#$% ^ 2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH <`< NormalCJ_HmH sH tH DA D Default Paragraph FontViV  Table Normal :V 44 la (k (No List 4B@4 Body Text5\2>@2 Title$a$5\PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  K  8@0(  B S  ?ϭ_Э_\dd;*urn:schemas-microsoft-com:office:smarttagsaddress:*urn:schemas-microsoft-com:office:smarttagsStreet  )++@A 12RX^~Jgh@A 1ghDHJK[|&㚹808^8`0o(.^`.pLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.[|pW6         #H! Ki^9c6q ;~9@(%dX@UnknownG*Ax Times New Roman5Symbol3. *Cx ArialA BCambria Math"h8禺禫  !xr4d2QHP ?6q2!xxINSURANCE VERIFICATION FORM UT Employee Emily Barnes Oh+'0  < H T `lt|INSURANCE VERIFICATION FORM UT EmployeeNormalEmily Barnes7Microsoft Office Word@~@z%@$@61!%՜.+,0 hp  University of Tennessee  INSURANCE VERIFICATION FORM Title  !"#%&'()*+-./01236Root Entry FB!%8Data  1TableSWordDocument4SummaryInformation($DocumentSummaryInformation8,CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q