Group Enrollment

Group Number

Personal Information:

First Name

Last Name

Middle Name

Student Category

Gender

Date of Birth

Confirm Email

Country of Origin

School

Student ID

Phone

U.S. Address Line 1

U.S. Address Line 2

City

State

Zip

Choose Your Plan

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Start Date

End Date

Consent Agreement:

Unless otherwise stated in the Master Policy, coverage will begin effective (if submitting via Online Services) the day the correct premium is submitted to the Company or the effective date of the coverage period, whichever is later. The student/visa holder is responsible for the timely renewal payments. By submitting this application, the student/visa holder acknowledges the following:
1). He/she has carefully read the certificate and elects to enroll as indicated on the application;
2). He/she declares they meet the eligibility requirements for the plan selected;
3). That if it is later determined that the student is not eligible, or upon entrance in the armed forces, the premium will be refunded. Premium will not be refunded except for ineligibility or entrance into the armed forces.

I have read and agree to the terms stated above, and I elect to purchase insurance coverage under this insurance plan. Above are choices I have made.

Signature:

By typing your name in this Signature field, you hereby certify that the information entered into this form is true and correct to the best of your knowledge.

Authorized Signature:

Date

Group Enrollment

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