This government document is issued by Maryland Insurance Administration for use in Maryland
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https://www.google.com/url?client=internal-element-cse&cx=007821330218074952993:f4zv_rasvj8&q=https://insurance.maryland.gov/Insurer/Documents/bulletins/19-23-Student-Health-Plan-Form.pdf&sa=U&ved=2ahUKEwiBn57qgYrxAhXisaQKHZsTBu0QFjAJegQICBAC&usg=AOvVaw2vJaAq1B5QedqCZDpEkYc1