Request Proof of Coverage

Important! Please read.


If you require Proof of Coverage for any of the reasons below please complete the form below.
  • You are leaving the country and require proof of worldwide coverage
  • Your new insurance company is requesting proof of coverage
  • Your college or university is requesting this for the program that you attend
  • Your plan with Bollinger will be terminating

Students Information

Student's First Name:


Student's Last Name:


Your Email:


Email Confirmation:


Student's Birth Date:


College Student Attended:


Phone:


Mailing Address:


City:


State:


Zip:


FAX Proof of Coverage to this number: (optional)


Comments: (optional)