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Date Insurance Coverage terminated. Last Date of Coverage between Check 8/15/2016 and 5/14/2017 5/15/2017 and 6/14/2017 The processing fee is a one-time charge Premium Due Premium will be charged to student account 413. If the 60 day deadline is missed coverage will be effective the day this form is postmarked or faxed to Gallagher Student Health Special Risk with the required documentation. If your coverage ended before May 15 2017 your student account will be charged the applicable...
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Address gendermalefemale refers to the gender fields on a form where individuals can indicate their gender as either male or female.
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