Student Accident & Sickness Insurance Enrollment Form
Academic Year 2014 - 2015
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 attending 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.
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. All coverage expires on the earlier of: the Master Policy expiration date 07-31-2015 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.
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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