Student Accident & Sickness Insurance Enrollment Form
Academic Year 2013 - 2014


Underwritten by:
Nationwide Life Insurance Company:
Home Office: Columbus, OH
Administrative Office: Student Assurance Services, Inc,
P.O. Box 196, Stillwater, MN, 55082-0196


For Domestic Students of St. Ambrose University


Click here to view the Insurance Brochure

Click here to view a hard copy of the Enrollment Form

If you choose to enroll by mail, download the enrollment form above,
complete the form and mail it with your payment to:
Student Assurance Services, Inc., P.O. Box 196, Stillwater, MN 55082-0196.


       If you choose to enroll online, payment is required by credit card.
       To enroll online complete the form shown below.

       There will be a $10.00 transaction fee charged for online enrollment.


       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: 
* Number of Dependents:
     
* Credit Card Type: 
* Credit Card Number: 
  CVV2:     see the back of your card
* Expiration Date:   /   (mm/yyyy)
* Cardholder Name: 
* Cardholder Address: 
* City: 
* State: 
* Zip: 
* Cardholder Phone Number: 
     
* Status: 



Dependent Information

  Name Soc. Sec. # Birthdate
Spouse
Child
Child

Coverage becomes effective on the later of: the Master Policy effective date 08-01-2013; the first day of the term for which the proper premium has been paid; or 12:01 A.M. following the date the proper premium is received by the Plan Administrator. All coverage expires on the earlier of: the Master Policy expiration date 07-31-2014 or when premium for your accident and sickness insurance coverage is due and unpaid. It is your responsibility to make timely premium payments regardless of whether or not you receive a premium notice. No refunds, except as provided in the Master Policy.

This plan has an enrollment period, refer to the online brochure. Premium includes an agent service fee. Spring/Summer and Summer may only be purchased by a new student not eligible for Annual or Fall coverage, or a student who purchased Fall coverage and wishes to continue coverage.

PREMIUM RATE
 Annual
08-01-2013
to
07-31-2014
Fall
08-01-2013
to
12-31-2013
Spring/Summer
01-01-2014
to
07-31-2014
Summer
05-15-2014
to
07-31-2014
Student Only - Age 25 and Under  $1197.00   $502.00   $695.00 $256.00
Student Only - Age 26 and Over  $1581.00   $672.00   $929.00 $348.00
Spouse  $4320.00  $1820.00  $2520.00 $934.00
Each Child  $2433.00  $1029.00  $1424.00 $531.00

Y-18IA(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 am agreeing to the eligibility requirements of enrollment as outlined in the brochure and important provisions above.


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

(Parent or guardian if under 18 years of age)

Please re-type the cardholder's 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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