Student Request for Insurance Information

Research, Environmental Health and Safety   |   Approved May 14, 2015

Purpose

Requesting proof of insurance or claims history.

Applicability

Students working in clinical settings as part of their academic program requesting confirmation of professional liability coverage or insurance claims history. 

The Office of Environmental Health and Safety (EHS) details academic programs currently covered on their website.

Instructions

Allied Health Program Graduates and Dental School Graduates

1. Complete the Request for Verification of UMB Student professional Malpractice Coverage and/or Claims History Form and fax request to EHS at 6-1520.
   1. If the student needs to have a form from an outside institution completed, the graduate must verify that the form includes all required information in UMB’s form, and append additional pages as required if the form is not as comprehensive as the form above.        This includes but is not limited to:
      1. Full name of the graduate (include maiden and/or married name);
      2. UM Student ID number;
      3. Date of birth;
      4. Current address, phone number, and email address; and
      5. School and program attended, degree obtained, and years enrolled at school.
   2. Forms must be signed by the graduate.
      1. If the name of the graduate is not the name that appears in current University records, evidence of change of name (e.g., copy of marriage license) must be provided. 
   3. Include restrictions such as if the outside institution requires the information must be sent directly to the requesting employer or academic institution.   
      1. If the information is not to be returned to the student, designate where information is to be mailed and whether the recipient will accept a facsimile or e-mail.     
2. Complete Request for Enrollment Verification to be sent to EHS c/o Angela Boxley, 714 W. Lombard Street, Baltimore, MD 21201.
3. EHS will review for completeness after verification of enrollment is received.
   1. Release forms must be signed by graduates and must contain all requested information or they will be returned for completion.
4. EHS will then forward the request to the appropriate State of Maryland office for further action.  The entire procedure can take up to 21 days.

Medical Students

1. Complete the Request for Verification of UM Student professional Malpractice Coverage and/or Claims History Form and fax to the attention of Pat Zichos at Maryland Medicine Comprehensive Insurance Program (MMCIP), Suite 200, University Square Building, 11 S. Paca Street, Baltimore, Maryland 21201.