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Student Dependent Attendance Report

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Mutual of Omaha Insurance Company
United of Omaha Life Insurance Company
Exclusive Healthcare, Inc.

For DentaBenefits Plans Only:
United Concordia Insurance Company
Concordia Dental Corporation of Alabama
United Concordia Life and Health Insurance Company
United Concordia Insurance Company of New York

This information is required to update our records on an annual basis.

To be Completed by Employee (Answer All Questions)

Employee Information
Name of Group:		Group ID:
First Name:		Last Name:
Email Address:
Student Information
First Name:		Last Name:
Birth Date:	(MM-DD-YYYY)
School, College, or University Information
Name:		Phone:
Address:		City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:
Identify Your Enrollment/Plans to Enroll for the Next 12 Months
Academic Period (You must enter at least one academic period.) Beginning Date Ending Date Number of Credit Hours or if vocational school provide Hours spent in daily attendance
Starting date of prior term:		Date that term ended:
Any breaks in attendance from beginning of school?   Yes    No
Anticipated date of graduation?
Is the student chiefly dependent upon you for support?   Yes    No
If "Yes," is this student reported as a qualified exemption on your federal income taxes? Yes    No
Is the student gainfully employed?   Yes    No
If "Yes," please supply the following information about the employer:
Employer:		Phone:
Address:		City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:
How many hours does the student work each week?
Does the student's employment provide group insurance?   Yes    No
If yes, please supply the following information:
Company:		Phone:
Address:		City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code:
I hereby certify the statements hereon are complete and accurate, and understand they will be used to help determine the eligibility of my dependent according to the provisions of the policy. Furthermore, I understand it is my responsibility to notify the Insurance Company of any change in the status of this dependent as relates to the above information.