Student Accident & Sickness Insurance Enrollment Form
Academic Year 2014 - 2015


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 International Students' Dependents of University of the Incarnate Word


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 $15.00 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 08-01-2014; 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 or University. All coverage expires on the earlier of: the Master Policy expiration date 07-31-2015, or when premium for your 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.


*Student premium includes an administrative fee charged by the University. All premium includes an agent service fee.

PREMIUM RATE
 Annual
08-01-2014
to
07-31-2015
Fall
08-01-2014
to
12-31-2014
Spring/Summer
01-01-2015
to
07-31-2015
Summer
05-01-2015
to
07-31-2015
Spouse  $3125.00  $1319.00  $1826.00 $798.00
Each Child  $2024.00   $858.00  $1186.00 $520.00

Z-12TX(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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