Student Accident & Sickness Insurance Enrollment Form
Academic Year 2017 - 2018


Underwritten by:
National Guardian Life Insurance Company
Home Office: Madison, WI
Administrative Office: Student Assurance Services, Inc.
P.O. Box 196, Stillwater, MN 55082


For International Students of Rice University



       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.


* First Name: 
* Last Name: 
  Middle Name: 
* Date of Birth:   (mm/dd/yyyy)
* Social Security:   (ex. 123-45-6789)
if you do not have a SSN enter 999-99-9999
  Student ID: 
* Address: 
* City: 
* State: 
* Zip: 
* Phone Number: 
* EMail: 
* Number of Dependents:
* Status: 



Dependent Information

  Name Soc. Sec. # Birthdate
Spouse
Child
Child

Coverage becomes effective on the later of: the Master Policy effective date 08-15-2017; 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 08-14-2018, 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.

PREMIUM RATE
 Annual
08-15-2017
to
08-14-2018
Fall
08-15-2017
to
12-31-2017
Spring
01-01-2018
to
08-14-2018
Student Only  $1312.00   $500.00 $812.00
Spouse  $1312.00   $500.00 $812.00
Each Child  $1312.00   $500.00 $812.00



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.



Please type your name in the space below to electronically sign your application:
Name: 
(Parent or guardian if under 18 years of age)
Date:   mm/dd/yyyy

TO BEGIN ENROLLMENT IN THIS INSURANCE PLAN, PLEASE CLICK ON THE "NEXT" BUTTON.




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