Student Accident & Sickness Insurance
Academic Year 2013 - 2014




For Students of Rockford University
Bill My Student Account


Click here to view the Insurance Brochure


       If you choose to enroll online, charges will be added to your student account.
       To enroll online complete the form shown below.


       Fields marked with an asterisk (*) must be filled in.
       At least one of the fields marked with a plus (+) must be filled in.


* First Name: 
* Last Name: 
  Middle Name: 
* Date of Birth:   (mm/dd/yyyy)
+ Social Security:   (ex. 123-45-6789)
+ Student ID: 
* Address: 
* City: 
* State: 
* Zip: 
* Phone Number: 
* EMail: 
* Status: 






IMPORTANT: Enrollment may only be completed for the current semester.

PREMIUM RATE
 Spring/Summer
01-01-2014
to
08-08-2014
STUDENT ONLY  $1210.00

Y-148IL(enr)

Electronic Signature

BY CHECKING THE BOXES AND ENTERING MY NAME BELOW I AM INDICATING MY INTENT TO ELECTRONICALLY SIGN THIS APPLICATION AND WARRANT THAT ALL OF THE INFORMATION I HAVE PROVIDED IS TRUE, COMPLETE, AND ACCURATE.

Acknowledgement
I understand by applying for coverage I agree to the eligibility requirements of enrollment as outlined in the brochure and important provisions above.

I understand that the policy excludes benefits for a pre-existing condition, not subject to credit for prior coverage, until I am continuously covered
under the policy for 12 months.
I understand that I am authorizing Rockford University to bill the premium amount to my student account.



Please type your name in the spaces below to electronically sign your application:
Name: 

(Parent or guardian if under 18 years of age)

Please re-type your name in the spaces below to confirm your electronic signature:

Name: 

Please type your city, state and the date (mm/dd/yyyy) below:

City
State
Date
 mm/dd/yyyy

I AGREE

TO BEGIN ENROLLMENT IN THIS INSURANCE PLAN, PLEASE CLICK ON THE "NEXT" BUTTON.




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