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


Student ID#:
Student Type:(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:
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METHOD OF PAYMENT


PLEASE CHECK ALL APPROPRIATE BOXES

  Summer
Student Plan
Student Premium: $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.

By checking the box below I agree that, once the University has verified that I am eligible for this insurance plan, the University of Colorado Denver has authorization to charge my Student Account for the Term of Coverage and premium listed above.

I am enrolling in the University of Colorado Denver, Downtown Denver Campus 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 understand that to be eligible I must be one of the following:

  1. A domestic undergraduate student taking 6 or more credit hours or a graduate student enrolled in a degree-seeking program at the University of Colorado Denver, Downtown Campus, or
  2. An International student with a visa status other than an F-1 or J-1 who is engaged in educational activities through the University provided he or she: 1) possesses a current valid visa; 2) is temporarily located outside his or her home country as a non-resident alien; and 3) is an undergraduate taking 6 or more credit hours or a graduate student enrolled in a degree-seeking program at University of Colorado Denver, Downtown Campus.

I understand that coverage in this student health plan will be void and never effective if the University does not verify that I am eligible for this plan. Students must actively attend classes the first 31 days of the semester for which the student purchased insurance coverage. If the student drops out of school or drops below the required amount of credit hours within the first 31 days, they are not eligible for the Student Health Plan and the entire cost of the coverage will be refunded. Such a student will not be entitled to any benefits during the days described above and no claims received will be honored.

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.


 By checking this box I acknowledge that I am electing to enroll in the University of Colorado Denver, Downtown Campus 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. My account will not be charged until my eligibility has been verified by my school.



Questions? Please call ECI Toll Free 866.780.3824