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 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.


       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 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.

PREMIUM RATE
 Annual
08-01-2013
to
07-31-2014
First Quarter
08-01-2013
to
11-30-2013
Second Quarter
12-01-2013
to
07-31-2014
Third Quarter
03-01-2014
to
07-31-2014
Fourth Quarter
06-01-2014
to
07-31-2014
Student Only  $2267.00   $767.00  $1520.00   $960.00 $373.00
Spouse  $6488.00  $2177.00  $4331.00  $2728.00$1048.00
Each Child  $4589.00  $1543.00  $3066.00  $1933.00 $744.00

Y-168WI(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.

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:
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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