GO Passport


	Individual & Family Health Plans

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	FAQs


	GO-TO: Health Plan Manager

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		GO You!

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Your GO Passport

Child's Full Name
Address
City
State
Zip code
Daytime Phone
Child's Age
Parent/Guardian name
Parent/Guardian email (optional)
Parent/Guardian initials
^{The parent/guardian must enter their initials in the above box to indicate agreement to the following statements: I give permission for my child to receive a Physicians Plus GO Passport and program information. I understand that I am completely liable for any actions of this child during program participation. I release Physicians Plus Insurance Corporation (.sponsor.) and all other partners in the promotion and their directors, officers, employees and agents from responsibility and any liability for any injury, losses or damages of any kind incurred by my child or any other person as a result of participation in this program and acceptance and use of any prize. I understand that I am responsible for any federal, state or local taxes that may be associated with winning a prize. I certify that the information I have provided is correct and that I have not committed fraud or deception in giving my permission for the child to participate in the program or in claiming any prize.}