2013-2014 UNIVERSITY OF COLORADO - COLORADO SPRINGS
STUDENT/DEPENDENT HEALTH INSURANCE ENROLLMENT FORM


Student ID#:
Divisional Information:(check one)



Coverage: (check one)
Student’s Last Name:
Student’s First Name:
Middle Initial:
Gender: (check one)
Date of Birth:
Mailing Address:
Please enter in the mailing address where you want your Insurance ID cards and Insurance information mailed to
Apt. or PO Box or Rural Route:
City:
Country:
State:
Zipcode:
Telephone #:
Email Address
If you are not enrolling a dependent(s) please proceed to bottom of form

Dependent Plan
Complete information below for Dependents to be insured.
Dependent coverage is available only for an eligible Student's Dependents insured under the Plan.

Spouse SSN:
Date of Birth:
Last (family) Name:
First (given) Name:
Middle Initial:
Gender: (check one)




Child SSN:
Date of Birth:
Last (family) Name:
First (given) Name:
Middle Initial:
Gender: (check one)




Child SSN:
Date of Birth:
Last (family) Name:
First (given) Name:
Middle Initial:
Gender: (check one)




Child SSN:
Date of Birth:
Last (family) Name:
First (given) Name:
Middle Initial:
Gender: (check one)




Child SSN:
Date of Birth:
Last (family) Name:
First (given) Name:
Middle Initial:
Gender: (check one)
EFFECTIVE & TERMINATION DATES

  Effective and Termination Dates Enrollment Deadline
Summer 06/09/2014  through  08/24/2014 06/16/2014


PLEASE CHECK ALL APPROPRIATE BOXES

Insured Category: All Regular Students

Class of Coverage Summer
Plan
Student
Spouse / Domestic Partner
Each Child
Each Child
Each Child
Each Child
Student Premium: $0 |  Dependent Premium: $0 |  Total Insurance Premium: $0

NOTE: The amounts stated above include certain fees charged by the school you are receiving coverage through. Such fees may include amounts which are retained by your school (to, for example, cover your school’s administrative costs associated with offering this health plan) as well as amounts which are paid to certain non-insurer vendors or consultants by, or at the direction of, your school.

I am enrolling in the University of Colorado - Colorado Springs 2013-2014 Student Injury and Sickness Insurance Plan for the term and coverage indicated above. I understand that coverage in this program is subject to verification by the University that I am eligible. I am a registered student enrolled in at least nine (9) credit hours or more as a degree-seeking undergraduate or six (6) hours or more as a degree-seeking graduate student at the University of Colorado Colorado Springs. (I understand that coverage in this student Insurance plan will be void and never effective if the University does not verify that I am eligible for this plan.) I understand payment must be made when submitting this form for enrollment.

Students enrolled in the Spring may purchase Summer Insurance without attending classes if the student was an eligible student during the Spring semester and is enrolled in the subsequent Fall 2013 semester at the time of enrollment.

NOTICE TO STUDENT: Coverage will be effective the date the correct premium is received by the Company or a representative of the Company or the effective date of the coverage period, whichever is later, unless otherwise stated in the Master Policy. By signing, the student acknowledges the following: 1) He/She has carefully read the brochure and elects to enroll as indicated on this enrollment card; 2) Rates are not pro-rated other than as listed on this enrollment card; 3) He/She meets the eligibility requirements for this coverage as described in the brochure; and 4) If it is later determined that the student is not eligible, the premium will be refunded. Premium will not be refunded except for ineligibility or entrance into the armed forces.

NOTICE: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

I specifically consent to the release of any of the above information which may be protected under the Family Educational and Privacy Rights Act including without limitations records of enrollment, attendance or payment of tuition related to my attendance at any Educational Institution to the blanket policyholder, AmeriBen, ECI or the Company, or their legal representatives.

Payment Instructions: Online payments can be made by check or credit/debit card by making the appropriate selection below. To pay by Money Order; contact ECI Services toll-free at 866-780-3824 for an offline form.



METHODS OF PAYMENT
There are two different payment options:

1. Credit/Debit Card: To pay by credit/debit card enter the required credit/debit card information. Your card will be processed immediately.

2. Electronic Check: To pay by electronic check fill out the ECI enrollment form and enter your check information as requested. Your check will be processed on the same business day.

HOW ARE YOU PAYING?

Your credit/debit card statement will read "ECI UHCSR Account” for your premium payment. This authorization allows ECI to charge my VISA, MASTERCARD, AMERICAN EXPRESS or DISCOVER CARD for premium payment.

Last Name:
First Name:
Card Number:
Expiration Date:
CVV Number:
My billing address is same as of mailing address
Address 1:
Address 2:
City
State:
ZipCode:

 By checking this box I acknowledge that I am electing to enroll in the University of Colorado Colorado Springs Student Injury and Sickness Insurance Plan. I also have read the program brochure which outlines the benefits and exclusions of the coverage I am purchasing. I also understand that by electing the specific enrollment period above; I am bound to the terms and dates of this enrollment period. I also understand that if I change my mind on electing this coverage after I click the submit key, there will be no refund returned, and no exceptions will be made; except if you enter into the Armed Forces, or drop below the required credit hours within the first 31 days of classes. Premium will not be charged until my eligibility has been verified by the University.



Questions? Please call ECI Toll Free 866.780.3824