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 Scholars 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.
       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)
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

Scholars are encouraged to submit their request for coverage in a timely manner. Coverage becomes effective on the later of: the Master Policy effective date 08-15-2017; or the date of the requested Effective Date of Coverage entered below; 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 08-14-2018; or last day of the calendar month for which the premium is paid; or the date of the requested Expiration Date of Coverage entered below.

Scholars must purchase a minimum of 3 months of coverage. Month means either a full or partial calendar year month. The premium is charged for each calendar month or partial calendar month during which a scholar's insurance is in force. For example, coverage from November 29th through January 29th would be 3 months.

* Scholar must complete the Effective and Expiration Date section below.

PREMIUM RATE
 Annual
08-15-2017 to
08-14-2018
*3 months*4 months*5 months*6 months*7 months*8 months
Scholar$1560.00 $390.00 $520.00 $650.00 $780.00 $910.00$1040.00
Spouse$1560.00 $390.00 $520.00 $650.00 $780.00 $910.00$1040.00
Each Child$1560.00 $390.00 $520.00 $650.00 $780.00 $910.00$1040.00


EFFECTIVE AND EXPIRATION DATES

  Requested Effective Date of Coverage (mm/dd/yyyy)
  Requested Expiration Date of Coverage (mm/dd/yyyy)
Scholars purchasing monthly coverage must enter the effective and expiration date for the coverage. Dependents must enroll when the scholar first enrolls in the insurance plan, and must enroll for the same coverage period as the scholar.


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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