2013-2014 UNIVERSITY OF COLORADO DENVER DOWNTOWN CAMPUS
STUDENT INJURY AND SICKNESS INSURANCE PLAN
DEPENDENT ENROLLMENT FORM


Student ID#:
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

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)

NOTICE TO STUDENT: Coverage will be effective on the effective date of the coverage period if payment is received by the Company or a representative of the Company or the Student Health Insurance Office by the Enrollment Deadline Date listed on this form. By clicking the submit box, the student acknowledges the following: I) He/She has carefully read the Student's Accident and Sickness Health Plan brochure and elects to enroll their dependent(s) as indicated on this enrollment form; 2) Rates are not pro-rated other than as listed on this enrollment form; 3) He/She is properly enrolled under the Student Accident and Sickness Health Plan and the dependents listed meet the eligibility requirements as listed in the brochure; and 4) If it is later determined that the student and/or dependent(s) are not eligible, the premium will be refunded. Premium will not be refunded except for ineligibility or entrance into the armed forces.


PLEASE CHECK ALL APPROPRIATE BOXES

Class of Coverage Summer
Spouse / Domestic Partner
Each Child
Each Child
Each Child
Each Child
$0 $0 Total Insurance Premium: $0
EFFECTIVE & TERMINATION DATES

  Effective and Termination Dates Enrollment Deadline
Summer 05/19/2014  through  08/17/2014 06/06/2014


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.

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



METHODS OF PAYMENT
There are three 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 immediately.

3. Money Order: Please fill out the form, submit the form and print a copy. Mail in the enrollment form with the Money Order to ECI Services 14142 Denver West Parkway, Suite 200, Lakewood, CO 80401

HOW ARE YOU PAYING?

Your credit/debit card statement will read "ECI (Student Insurance)" 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 am acknowledging that I am electing to enroll in the University of Colorado Denver Downtown Campus Student Accident and Sickness Health Plan, Designed for Students and their Dependents. 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, or are approved for disenrollment by the Carrier before the enrollment deadline. (Contact ECI for further information 866-780-3824.) Premium will not be charged until eligibility of the Student has been verified by the University of Colorado Denver Downtown Campus.



Questions? Please call ECI Toll Free 866.780.3824