Student Accident & Sickness Insurance Enrollment Form
Academic Year 2014 - 2015
Columbian Mutual Life Insurance Company:
Home Office:Vestal Parkway E., P.O. Box 1381, Binghamton, NY 13902-1381
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.
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.
|Spouse|| $3125.00|| $1319.00|| $1826.00|| $798.00|
|Each Child|| $2024.00|| $858.00|| $1186.00|| $520.00|
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 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:
(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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