Student Information (Items in RED must be filled in)
Student Name:
Mailing 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 Catastrophic plan option

Enrollee Annual Six (6) Months Three (3) Months   Student  Under 25 $ 276.00 25 & Over   $ 0458.00 Under 25 $ 138.00 25 & Over $ 229.00 Under 25 $ 069.00 25 & Over $ 115.00   Spouse   $ 741.00   $ 1072.00 $ 371.00 $ 536.00 $ 185.00 $ 268.00   Each Child   $ 376.00   $ 0376.00 $ 188.00 $ 188.00 $ 094.00 $ 094.00

Other Questions, Comments, or Requests: