Section 5 of 12: Insurance (LI0228)

Contents -

Section 5 of 12: Insurance (LI0228)

This section captures the information with regard to insurance coverage.

Program Insured?

Select either Yes or No by using the radio button next to the field ().

Policy Holder Name

Enter the name of the policy holder in this field.

Insurance Agency Name

Enter the name of the insurance agency in this field.

Policy Date

Enter the date of the policy using the format MM/DD/YYYY.

Policy Effective Date

Enter the effective date of the policy in this field using the date format MM/DD/YYYY.

Policy Expiration Date

Enter the expiration date of the policy in this field using the date format MM/DD/YYYY.

Policy Number

Enter the number that appears on the policy in this field.

Location Address

Enter the first line of the Address in this field.

Address Line 2

Enter the second line of the Address in this field.

City

Type the name of the city in this field. If the provider is located outside of Vermont, this field should be completed.

Town

Select the name of the town by using the down arrow () next to the field. If the provider is located in Vermont, this field should be completed.

State

The State has been defaulted to Vermont; however if another selection is needed, select the name of the state by using the down arrow () next to the field.

Zip Code

Enter the zip code in this field using the format #####-####.