CARE Insurance Change Request Form

This form is to be utilized ONLY if:
  1. You have applied and been approved for a 2021 CARE Grant
  2. You now have a change in your insurance and wish to request a change in your 2021 grant funding 
CARE funding for any grant calendar year requires grantees to notify the NGCF as soon as any changes in insurance occur. Failure to notify the NGCF of any changes in insurance may lead to grant termination.

Primary Insurance Information

Secondary Insurance Information

Pharmacy Insurance Information

Dental Insurance Information

Vision Insurance Information

Other Insurance Information

You are required to submit Proof of Insurance with this request.

Proof of Insurance is:

  • A copy of your notification regarding your NEW insurance premium cost which includes the initiation date of coverage.


  • A copy of your most current invoice for the NEW insurance indicating the premium cost & initiation of coverage date


  • A copy of your most current paycheck indicating the cost of your NEW insurance (if insurance is provided through employer)

It is your responsibility to ensure the proof of insurance you are providing accurately reflects the 2021 premium for each policy. 

Please note that it is possible for requests made to be denied due to request exceeding available CARE funds. This form in no way guarantees the approval of additional requested grant funds.