As your covered dependent prepares to attend or attends, college, it's important to make certain that he or she continues to receive health benefits. Please be sure to check your benefit book to confirm dependent full-time student eligibility terms.
Members with covered college student dependents who are under the maximum dependent full-time student coverage age must submit a Student Coverage Questionnaire by December each year to ensure their dependents’ continued health benefits.
In order for college student dependents under the maximum coverage age to retain coverage, Empire requires that your child attend an accredited school of higher learning full-time, and that you submit the Student Coverage Questionnaire by December 31 of each year to establish eligibility for continued enrollment.
Download and print the Student Coverage Questionnaire Form, which is also available in the "Forms and Documents" page under Member Services.
You are responsible for completing the questionnaire and certifying that the information is correct. The form requires, in addition to basic information:
the name and address of the educational institution
type of institution, and
expected date of the student’s graduation or completion
Completed and signed forms should be faxed or mailed to the following:
FAX to:
1-800-780-1224
MAIL to:
Empire
PO Box 1407
Church Street Station
New York, NY 10008-1407
