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INSURANCE INFORMATION Child's Name Insurance Company Policy # Group # Address City State Zip MEDICAL HISTORY MY CHILD, named above: 1. Has a history of epilepsy: Yes No 2. Has a history of diabetes:
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What is my child named above?
Your child named above is named [child's name].
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The person required to file your child named above is [your name or guardian's name].
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You must report basic information such as name, date of birth, social security number, and any income or financial accounts held in the child's name.
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