Continuation Insurance Enrollment Form Page 2
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1
2Blue Cross and Blue Shield of Texas
UNIVERSITY OF TEXAS AT BROWNSVILLE
101470-14
CONTINUATION INSURANCE ENROLLMENT FORM
2014–2015 STUDENT HEALTH INSURANCE PLAN
Student Name_________________________________________
UT Login __________________________________
(must be provided to be processed)
The premium must be received within 30 days after the UT Brownsville Student Health Insurance Plan terminates.
PLEASE CHECK ALL APPROPRIATE BOXES:
Period of Coverage Requested:
Effective Date:
Termination Date
PREMIUM COST
Please check the appropriate box:
Coverage:
Monthly Rate
Do you have other insurance?
Yes
(6 month maximum)
No
Student
$
233.00
If yes, Insurance Company Name
Spouse
$
659.00
Each Child
$
362.00
Policy Number
Total Amount Due:
$
Please attach a copy of your current Insurance ID card.
Please Note: The Continuation Privilege will allow you to purchase up to a maximum of six (6) consecutive months of coverage. Incorrect payment amounts will be returned and
no coverage will be in effect.
The fi nal cost will include a $15 processing fee. Please use the chart below to calculate total amount due.
CALCULATE TOTAL PREMIUM DUE
Step 1 - Choose all desired premium above | Step 2 - Write the amount chosen in the applicable column(s) below
Step 3 - Calculate and submit total due.
Example: Student + Spouse + Child x # of Months + Processing Fee = Total
($233 + $659 + $362 x 3 + $15 = $3,777)
Student Rate
Spouse Rate
Each Child
# of Months
Subtotal
Processing Fee
Total Amount
Rate
Due
x
$15.00
=
+
+
+
=
PAYMENT INFORMATION: Make check or money order payable to Blue Cross and Blue Shield of Texas in U.S. dollars or refer to the charge card
authorization to charge your premium to Visa, MasterCard, or Discover. Mail this enrollment form along with premium payment to Academic HealthPlans, P.O. Box
1605, Colleyville, TX 76034-1605 or fax to (817) 809-4701 if paying by credit card. If you have questions, please call Academic HealthPlans at (855) 247-7587..
Your cancelled check or credit card billing is your only receipt and notifi cation of coverage.
PAYMENT OPTIONS
Charge Full Amount
$
Check Amount
$
VISA
MasterCard
Discover
Check Number
Credit Card Number
Expiration Date
________/________
Month
Year
By signing this form, I hereby authorize Academic HealthPlans to initiate a credit card transaction for the payment of my premium. I understand my
insurance will be cancelled if my credit card is declined. All charges will show on my credit card statement as Academic HealthPlans, Inc.
SIGNATURE OF CARDHOLDER: ___________________________________________________ DATE ______________________
PRINTED NAME OF CARDHOLDER: _______________________________________________
DATE ______________________
I was a student at The University of Texas at Brownsville. I am presently insured under the UT Brownsville Student Health Insurance Plan and wish to enroll for
Continuation Coverage. I have read the brochure and elect to enroll myself (and my Dependents, if applicable) as shown above.
STUDENT’S SIGNATURE: ______________________________________________________ DATE: ________________________
(Signature of Student or Parent if Student is under age 18)
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Academic HealthPlans, Inc. (AHP) is a separate company that provides program management and administrative services for the student health plans of Blue Cross and Blue Shield of Texas.
AHP-EF2CONT(14) UTB
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