Submit or Update Insurance information "*" indicates required fields Use this form to submit a photocopy of your insurance information. Client's First Name* First Client's Last Name* Last Phone*Email* Client's Date of Birth* MM DD YYYY Office Location*Bay CityGrosse PointeMidlandMount ClemensPort HuronSaginaw How would you like to submit your insurance information?*Submit ImagesSubmit Details- Please allow this app to access your camera. - Please take individual images of both: 1. Drivers License or ID 2. Insurance Card FRONT and BACKDriver's License or ID (FRONT)* Drop files here or Select files Max. file size: 768 MB. Driver's License or ID (BACK)* Drop files here or Select files Max. file size: 768 MB. Insurance Card (FRONT)* Drop files here or Select files Max. file size: 768 MB. Insurance Card (BACK)* Drop files here or Select files Max. file size: 768 MB. Insurance TypePrimarySecondaryInsurance Provider* Policy ID / Enrollee ID* Policy Group Number* Insurance Company Phone NumberRelationship to Insured*SelfSpouseChildFirst Name of Insured (If other than self)* First Last Name of Insured (If other than self)* Last Policy Holder's Date of Birth* Month Day Year EmailThis field is for validation purposes and should be left unchanged. Copyright 2020 © Renewal Christian Counseling Center
