To completely fill out the Contact Information Form that we provide, you will need to know the following:

• Name, date of birth, address and phone number of the client/device user
• Name, title, address, phone number and e-mail of the person completing the form
• Name, address, phone number, policy expiration date and ID number of the Primary Insurance
• Name, address, phone number, policy expiration date and ID number of the Secondary Insurance (if applicable)

For more information, or to request a Funding Packet, please contact the Funding Department.