Student Health Insurance Enrollment Form

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2015-2016 Student Health Insurance Enrollment Form

Name*

First Name

Initial

Last Name

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Phone*

Date of Birth*

Gender*

Male Female

Student ID #*

Social Security #*

Program*

Undergraduate Graduate/Seminary/DCP International

School

Enrollment Period

Enrollment Period*

Entire Year (8/15/15-8/14/16) $2,495 (Deadline 9/18/15) (bill will be broken down into 2 semesters totaling $2,495) Fall Only (8/15/15-12/31/15) $943 (Deadline 9/18/15) Spring/Summer Only (1/1/16-8/14/16) $1,552 (Deadline 1/31/16) Enrolling after deadline; please prorate insurance cost

*If enrolling after the deadline, contact Student Life for the prorated cost based on enrollment date

Enrollment Period*

Entire Year (8/15/15-8/14/16) $1,884 (Deadline 9/18/15) (bill will be broken down into 2 semesters totaling $1,884) Fall Only (8/15/15-12/31/15) $713 (Deadline 9/18/15) Spring/Summer Only (1/1/16-8/14/16) $1,1 (Deadline 1/31/16) Enrolling after deadline; please prorate insurance cost

*If enrolling after the deadline, contact Student Life for the prorated cost based on enrollment date

Coverage Effective Date

Coverage Effective Date*

If applying after deadline, attach any documentation regarding significant life event

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Notice to Student

I have carefully read the brochure and elect to enroll as indicated. Rates are not pro-rated other than as listed. I permit the University to provide Regence BlueCross BlueShield of Oregon with my enrollment status for purposes of eligibility under this Plan. 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 the policyholder 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 Oregon Division of Insurance within the department of regulatory agencies.

Electronic Signature (type your name below)*

First Name

Last Name

Date/Time