Personal Representative Appointment

I, ______________________________________________________ (student), do hereby

                                                  (please print)

appoint _____________________________________________ (parent/guardian) as my

                                                              (please print)

personal representative to act on my behalf in the matters of health insurance with Student

Insurance and Student Resources.

I understand this is a voluntary designation and that this designation gives the personal

representative the same rights to my health insurance information as myself.  This appointment

will expire at the end of the current academic/policy year.

Please complete the following information:

____________________________________            ____________________________________

                                Insured’s Name                                                                                   Personal Representative’s Name

_____________________________________          ____________________________________

                         Insured’s Policy Number                                                                                            Street Address

_____________________________________          ____________________________________

                          Insured’s Student ID Number                                                                                 City, State, Zip Code

_____________________________________          ____________________________________

                                           Date                                                                                                              Date

_____________________________________          ______________________________                                                        Insured’s Signature                                                                         Personal Representative’s Signature

                                                                                Mail to:  Brenda Dutcher

                                                                                                Colgate University

                                                                                                13 Oak Drive

                                                                                                Hamilton, NY   13346