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Verification of Dependent Eligibility

Contact Info

Name

Phone

( ) - x

Dependent Info

Dependent first name

Dependent last name

Is your dependent child employed?

The completed form can be faxed to (406) 523-3187 or toll-free to 1-800-257-0950, or mailed to:

Allegiance – Enrollment Department
PO Box 3018
Missoula, MT 59806

Please do not hesitate to contact us if you have any questions. Our Enrollment Department Team may be reached at 1-800-877-1122.

By submitting this information you are stating that the information, to the best of your knowledge, is correct.