Student Information (Items in RED must be filled in)
Student Name:
School
Street Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####    FAX ###-###-####
Student E-mail:	Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                     no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                     no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                     no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                     no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                     no dashes
Dependent Information (Items in RED must be filled in)
Name:
Relation to Student	Choose the appropriate Relation to the Student Spouse Child      Gender   Choose Male Female
Date of Birth:	MM/DD/YYYY     SSN or Student ID#                     no dashes
Billing Information (Items in RED must be filled in)
Name:
Street Address:
City:
State:	Postal (Zip) Code:
Phone:	###-###-####
FAX:	###-###-####
Your E-mail:
Credit Card Information
Credit Card:	(No spaces or dashes)      EXP DT: (MM/YY) We accept  VISA/Mastercard
Card ID #:

Choose the appropriate Student/Dependent Catastrophic Plans
Qty	Type	Description / Price
	Student	Select the appropriate Plan and Term ------------------------------ Student - Annual 2007-2008 Rate - $25
	Spouse	Select the appropriate Plan and Term ------------------------------ Spouse - Annual 2007-2008 Rate - $25
	Child	Select the appropriate Plan and Term ------------------------------ Child - Annual 2007-2008 Rate - $25

Other Questions, Comments, or Requests: