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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.
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:
- 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
- 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.