Full Time Student Verification Form 

Form No :1.02

Purpose of Form : Complete this form if any dependants are either going to be turning 19 or are full time students between the ages of 19 to 23.

Edition Date : 05/01/2008

Where to File : Please return completed form in the enclosed self-addressed envelope within 30 days regardless of their status. Failure to do so may result in termination. You may choose to fax your form to: 330-454-7845 Attn: FTS

Special Instructions :AultCare verifies dependent information annually to insure that claims are being processed according to your plan’s guidelines. Please complete either Section A or B entirely depending on your dependent’s status. Incomplete forms will be returned to the member. You may visit our website to update this information online.