Student Accident & Sickness Insurance Enrollment Form
Academic Year 2013 - 2014
Nationwide Life Insurance Company:
Home Office: Columbus, OH
Administrative Office: Student Assurance Services, Inc,
P.O. Box 196, Stillwater, MN, 55082-0196
For Students of Milwaukee School of Engineering
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.
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 the premium for the 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. Any refund provided is subject to a $25 administration fee.
Premium includes an agent service fee. Second quarter, third quarter and forth quarter may be purchased by a new student not eligible to enroll for annual coverage or a student who purchased first quarter and wishes to continue coverage.
This plan has an enrollment period, please refer to the online brochure.
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 am agreeing 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.
Please type the cardholder's name in the spaces below to electronically sign your application:
(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:
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.
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