Flu Shot – Insurance Information

Please complete the form below for each participant.
Participant Name*

First

Last

Suffix
Participant Date of Birth*

Month

Day

Year
Insurance Company Name*
Insurance Company Name*
Insurance Company Phone Number*

Located on the back of your card.
Member ID*
Group ID*

If you only have one ID number on your card, please list the same ID number under both the Member ID and the Group ID.
Group Name*
Participant's Relationship to Primary Insured*
Primary Insurance Holder's Name*

First

Last

Suffix
Primary Insurance Holder's Date of Birth*

Month

Day

Year
Primary Insurance Holder's Employer
Insurance Card Image - Front
Max. file size: 5 MB.
Insurance Card Image - Back
Max. file size: 5 MB.
Unique ID