Insurance ID Card Template

INSURANCE ID CARD TEMPLATE

Cardholder and Insurer

Insurer Name:

Policy & Coverage Summary

Card ID:    Group#:    Policy#:

Plan Type:    Network:

Prescription Information: BIN    PCN    Group

Coverage Effective Date:    Coverage Expiration Date:

Covered Services (select all that apply)

Medical Dental Vision Prescription Behavioral Health Maternity

Exclusions & Limitations

The following is a concise statement of typical exclusions and limitations applicable to benefits reflected on this card. Coverage is subject to the terms, conditions, limitations and exclusions of the policy or contract. This card does not amend, extend or alter the policy. Services not expressly covered under the policy, services deemed experimental or investigational, cosmetic procedures, and services provided outside the approved network when required by the policy, may be excluded.

Beneficiary / Emergency Contact

Claims & Issuance

To report a claim or verify eligibility, contact: . Additional administrative contact:

Card Issue Date:

Declaration & Certification

I certify that the information on this card is a true and accurate representation of the insured's coverage as issued by the insurer identified above. This card is provided for identification and billing purposes only and does not constitute a contract of insurance. Coverage, eligibility and benefit determination are governed solely by the terms of the applicable policy, certificate or contract. The insurer reserves the right to correct clerical errors and to deny benefits where policy terms, exclusions, limitations or applicable law preclude payment.

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