Enrollment Form For Voluntary Students And Their Dependents Page 2
ADVERTISEMENT
1
2KENNESAW STATE UNIVERSITY
2015-599-1
Campus/School Attending: ___________________________________________________
Please print name of University. Must be completed in order for application to be processed.
I elect to purchase Injury and Sickness insurance coverage under the University’s student insurance plan. Below are
☐
the choices I have made.
PLEASE CHECK ALL APPROPRIATE BOXES.
INSURED CATEGORY:
Undergraduate
☐ Practical Training
☐
Other - Graduate
☐
ID Codes
Annual (A-)
Fall (F-)
Spring/Summer (J-)
6
Student
☐ $ 2,025.00
☐ $ 847.00
☐ $ 1,178.00
7
Spouse
☐ $ 2,025.00
☐ $ 847.00
☐ $ 1,178.00
8
One Child
☐ $ 2,025.00
☐ $ 847.00
☐ $ 1,178.00
9
Two or More Children
☐ $ 4,050.00
☐ $ 1,694.00
☐ $ 2,356.00
10
Spouse and 2 or More Children ☐ $ 6,075.00
☐ $ 2,541.00
☐ $ 3,534.00
ID Codes
Summer (S-)
6
Student
☐ $ 509.00
7
Spouse
☐ $ 509.00
8
One Child
☐ $ 509.00
9
Two or More Children
☐ $ 1,018.00
10
Spouse and 2 or More Children ☐ $ 1,527.00
EFFECTIVE/EXPIRATION PERIODS:
☐ Annual
8/1/2015
to 7/31/2016
☐ Fall
8/1/2015
to 12/31/2015
☐ Spring/Summer 1/1/2016
to 7/31/2016
☐ Summer
5/1/2016
to 7/31/2016
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.
EF-2014
2 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical