Student Accident & Sickness Insurance Enrollment Form
Academic Year 2013 - 2014


Underwritten by:
Nationwide Insurance Company
Home Office:
Columbus, OH
Administrative Office: Student Assurance Services, Inc,
P.O. Box 196, Stillwater, MN, 55082-0196

Voluntary Plan for Dependents of Graduate Assistants at Marquette University


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:
American Management Advisors, Inc.,
P.O. Box 366
Langhorne, PA 19047.
 

Please follow these steps if you would like to enroll your dependents in the College sponsored health insurance plan for the 2013-2014 academic year.

Student Information

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.
      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. 422-03-0032)
+ Student ID: 
* Address: 
* City: 
* State: 
* Zip: 
* Phone Number: 
* EMail: 
* Number of Dependents:
     
* Credit Card Type: 
* Credit Card Number: 
  CVV2:     see the back of your card
* Expiration Date:   /   (mm/yyyy)
* Cardholder Name: 
* Cardholder Address: 
* City: 
* State: 
* Zip: 
* Cardholder Phone Number: 
     
* Status: 

 

Dependent Information

  Name Soc. Sec. # Birthdate
Spouse
Child
Child
Child

Coverage becomes effective on the later of: the Master Policy effective date 08-01-2013; the first day of the term for which the proper premium has been paid; or 12:01 A.M. following the date the proper premium is received by the University or Plan Administrator. All coverage expires on the earlier of: the Master Policy expiration date 07-31-2014, or when 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 includes an agent service fee. This plan has an enrollment period, refer to online brochure.
* Spring/Summer and Summer may be purchased by a new student not previously eligible to enroll for Annual or Fall coverage or a student who purchased Fall coverage and wishes to continue coverage.

PREMIUM RATE
 Annual
08-01-2013
to
07-31-2014
Fall
08-01-2013
to
01-12-2014
*Spring/Summer
01-13-2014
to
07-31-2014
Spouse  $6619.00  $2758.00  $3861.00
Each Child  $4921.00  $2051.00  $2870.00

 



 

Electronic Signature

BY ENTERING THE INFORMATION ABOVE AND CLICKING THE SUBMIT BUTTON,  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.

Acknowledgement
I understand by applying for coverage I am agreeing to the eligibility requirements of enrollment as outlined in the brochure and important provisions above.

I understand that the policy excludes benefits for a pre-existing condition, not subject to credit for prior coverage, until I am continuously covered under the policy for 12 months.

 

Other Questions, Comments, or Requests:

 

Copyright 2007-2014 American Management Advisors, Inc
All Rights Reserved.