Student Accident & Sickness Insurance Enrollment Form
Academic Year 2018 - 2019


Underwritten by:
Commercial Casualty Insurance Company
Springfield, MA


For International Students of Rice University


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.


       Fields marked with an asterisk (*) must be filled in.


* First Name: 
* Last Name: 
  Middle Name: 
* Date of Birth: 
 (mm/dd/yyyy)
* Gender: 
* Social Security: 
 
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 * Gender
Spouse
Child
Child

Coverage becomes effective on the later of: the Master Policy effective date 08-15-2018; the first day of the term for which the proper premium has been paid; or 12:01 a.m. on 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 08-14-2019, 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
08-15-2018
to
08-14-2019
Fall
08-15-2018
to
12-31-2018
Spring
01-01-2019
to
08-14-2019
Student Only  $1433.00   $546.00   $887.00
Spouse  $1433.00   $546.00   $887.00
Each Child  $1433.00   $546.00   $887.00



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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