Enrollment Form For Standalone Repatriation/medical Evacuation Page 2
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2EAST GEORGIA STATE COLLEGE
2016-202727-4
NOTE: Please visit for the UnitedHealthcare Global brochure which includes service descriptions
and program exclusions and limitations. All services must be arranged and provided by UnitedHealthcare Global, any services not
arranged by UnitedHealthcare Global will not be considered for payment.
PLEASE CHECK ALL APPROPRIATE BOXES.
INSURED CATEGORY:
☐ Standalone Repatriation/Medical Evacuation
ID Codes
Annual (A-)
Fall (F-)
Spring/Summer (J-)
6
Student
☐ $ 75.00
☐ $ 31.00
☐ $ 44.00
7
Spouse
☐ $ 75.00
☐ $ 31.00
☐ $ 44.00
8
One Child
☐ $ 75.00
☐ $ 31.00
☐ $ 44.00
NOTICE: UnitedHealthcare Global will be effective the date the correct amount due is received by UnitedHealthcare
StudentResources or the Effective Date of the coverage period, whichever is later.
EFFECTIVE/EXPIRATION PERIODS:
☐ Annual
8/1/2016 to 7/31/2017
☐ Fall
8/1/2016 to 12/31/2016
☐ Spring/Summer 1/1/2017 to 7/31/2017
Payment Instructions: Make check or money order payable to UnitedHealthcare StudentResources in US dollars. Mail this
enrollment card along with premium payment to:
UnitedHealthcare StudentResources
PO Box 809026
Dallas, TX 75380-9026.
Your cancelled check or credit card billing is your only receipt and notification of coverage. The student is responsible for timely
premium payments whether or not a premium notice is received.
To enroll online: If you would like to use a credit card to enroll, please go to
and select the Enroll Now link
to enroll online.
SA-EF-2015
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Parent category: Medical