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:


Mailing Address:




FAX Proof of Coverage to this number: (optional)

Comments: (optional)