| Underwritten by: National Union Fire Insurance Company of Pittsburgh, Pa. of Pittsburgh, Pa. with its principal place of business in New York, NY |
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| Insured ________________________ | |
| Student ID# ________________________ | |
| Student of WESLEY COLLEGE 2010-2011 Student Insurance Plan Policy #CHH0057571 |
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| Both the effective and termination dates of coverage are subject to verification by the Insurance Company. (Address on reverse side.) |
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In the event of injury or sickness, the student should go to the Student Health Center first. (a) Secure treatment, procure instructions for claim procedure from the Student Health Center and follow instructions. (b) Notification of injury or sickness must be provided within 30 days after the date of accident or commencement of sickness to: Maksin Management Corp PO Box 2647 Camden, New Jersey 08101-2647 1-877-775-5430 (c) During vacation periods claim report forms and instructions may be obtained from the above. Express Scripts - Bin: 003858; Processor Control: A4; Group Number: AQ3A |