QBE MEDICAL INSURANCE VERIFICATION FORM

QBE requires that all their participants have health insurance. Please complete this form so that we will have all necessary information on file. It is your responsibility to make sure your personal or family policy will provide medical coverage in Europe for the duration of the course.

Participant's Name *
Participant's Name
Participant's Date of Birth *
Participant's Date of Birth
Under whose name is the policy issued? *
Under whose name is the policy issued?
Address *
Address
Date of Birth
Date of Birth
Address where claims must be submitted
Address where claims must be submitted