2013-2014 UNIVERSITY OF COLORADO DENVER DOWNTOWN CAMPUS
STUDENT INJURY AND SICKNESS INSURANCE PLAN
DEPENDENT ENROLLMENT FORM
COMPLETE INFORMATION BELOW FOR DEPENDENTS TO BE INSURED.
Dependent coverage is available only for an eligible Student's Dependents insured
under the Plan.
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
EFFECTIVE & TERMINATION
$0 Total Insurance Premium:
Effective and Termination Dates
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
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
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.