Form Ahp-Ef2 - Gap Scholar Health Insurance Enrollment Form

UNIVERSITY OF TEXAS SYSTEM 2015-2016

101464-15 - Medical | 106145-15 - Dental

GAP SCHOLAR HEALTH INSURANCE ENROLLMENT FORM

Visiting Scholars and their Dependents

(PLEASE PRINT CLEARLY or TYPE)

First

Middle Initial

Last

Scholar’s Name

Street or P.O.Box

City

State

Zip Code

ID Card Mailing Address

(Month/Day/Year)

Termination Date of Current

Phone/Cell Number

(

)

—

Insurance Coverage

(A confirmation email will be sent upon enrollment)

(Must be provided to be processed)

(Month/Day/Year)

Date of

Male

Female

SSN

UT EID

Birth

List Dependents to be insured below. Dependent enrollment must take place at the time of scholar enrollment, with the exception of newborn

or adopted children or a qualifying event. Dependent coverage is available only if the scholar is also insured. Dependent coverage must be the exact

same coverage period of the Insured; and therefore, will expire concurrently with that of the scholar.

Date of Birth

Gender

First Name

Last Name

Social Security Number

(MM/DD/YY)

(M/F)

Spouse

—

Child

—

Child

—

NOTICE TO SCHOLAR AND CARDHOLDER: Coverage will be effective the date the correct premium is received by the Company or an

authorized representative of the Company, or the effective date of the coverage period, whichever is later, unless otherwise stated in the Master Policy.

By signing below, the scholar and cardholder acknowledges the following: 1) Rates are not pro-rated other than as listed on this enrollment form; 2)

Scholar meets the eligibility requirements for this coverage as described in the brochure; 3) If it is later determined that the scholar is not eligible,

coverage will be deemed to have not been in force and the premium will be returned; and 4) Other than eligibility or entry into the Armed Forces, the

premium is not refundable. It is the scholar’s responsibility to make a timely renewal payment. This plan is underwritten by the Blue Cross and Blue

Shield of Texas.

I understand my information is protected by privacy laws and will be released only in accordance with these laws.

My signature below certifies that I have read and understand the Student Health Insurance Plan brochure and agree to accept

it as applicable to me regarding the terms and conditions stated therein.

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties

include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided

by the applicant.

SCHOLAR’S SIGNATURE: ______________________________________________________

DATE: _______________________

(Signature of Scholar, or Parent if Scholar is under age 18)

CARDHOLDER’S SIGNATURE: __________________________________________________

DATE: _______________________

Please note this enrollment form cannot be processed unless you make all your coverage selections on the reverse side.

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 scholar health plans of Blue Cross and Blue Shield of Texas.

AHP-EF2(15) UTSYSTEM

Form Ahp-Ef2 - Gap Scholar Health Insurance Enrollment Form - Bcbs Form

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