Student Accident & Sickness Insurance
Academic Year 2013 - 2014
For Students of Rockford University
Bill My Student Account
Click here to view the Insurance Brochure
IMPORTANT: Enrollment may only be completed for the current semester.
|STUDENT ONLY|| $1210.00|
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.
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:
(Parent or guardian if under 18 years of age)
Please re-type your name in the spaces below to confirm your electronic signature:
Please type your city, state and the date (mm/dd/yyyy) below:
TO BEGIN ENROLLMENT IN THIS INSURANCE PLAN, PLEASE CLICK ON THE "NEXT" BUTTON.
If you are experiencing any problems with this page please contact the webmaster.