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 Post Graduate International Students of 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 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
  1 Month 2 Months 3 Months
Student  $368.00  $736.00  $1104.00

 



 

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.