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Student Dependent Attendance Report

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Student Dependent Attendance Report
Mutual of Omaha Insurance Company
Companion Life Insurance Company
United Concordia Insurance Company of New York (for DentaBenefits plans only)

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

Policy/Plan Number

First Name

Last Name

Email Address

Student Information

First Name

Last Name

Birth Date

(MM-DD-YYYY)

School, College, or University Information

Name

Phone Number

( ) -

Address

City

State

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 Number:

( ) -

Address

City:

State

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 Number

( ) -

Address

City

State

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.

MUG5335_0603NY