If you are not enrolling a dependent(s) please proceed to bottom of form
EFFECTIVE & TERMINATION
Complete information below for Dependents to be insured.
Dependent coverage is available only for an eligible Student's Dependents insured
under the Plan.
PLEASE CHECK ALL
Insured Category: All Regular Students
Effective and Termination Dates
Total Insurance Premium:
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.
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.