Student Accident Insurance Enrollment Form
Academic Year 2019 - 2020

Plan E-129


Underwritten by:
Ameritas Life Insurance Corp.
Lincoln, Nebraska
Wellfleet Insurance Company
Springfield, MA

South Texas College
Voluntary Coverage


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.


       If you choose to enroll online, payment is required by credit card.
       To enroll online complete the form shown below.

       There will be a $5.00 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: 
 
if you do not have a SSN enter 999-99-9999
* Student ID: 
* Address: 
* City: 
* State: 
* Zip: 
* Phone Number: 
* EMail: 
* Status: 





Coverage becomes effective on the later of: the Master Policy effective date 08-26-2019; or 12:01 A.M. following the date the enrollment form and premium payment is received by the college, company or its authorized agent; or for online enrollment 12:01 A.M. following the date the proper premium is received by the Plan Administrator. All coverage expires on the Master Policy expiration date 08-25-2020. No refunds, except as provided in the Master Policy. Premiums are not prorated.

PREMIUM RATE
 Policy Year
One Time Rate
School Time Coverage  $75.00
Full Time Coverage (24 hour) $160.00

GAA-2203 Ed.11-16 E-129TX


      
ADDITIONAL COVERAGE
   


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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