University of North Florida 2010-2011
Domestic Student Health Insurance Enrollment Form
Student’s Name (Last, First, Middle) Date of Birth Sex: Female Male
______/______/______ ❒ ❒
Permanent U.S. Address (Street, City, State, Zip) Social Security Number
Phone #: ( ) Expected Graduation Date: Domestic Student: E-mail Address:
Dependent coverage is available only if the student is insured under this plan and the coverage periods must be the same.
List below dependents to be insured.
Last Name First Name Social Security # Male/Female Date of Birth
Premium Rates Please check all appropriate boxes.
Annual Fall Spring/Summer Summer
8/23/10 – 8/22/11 8/23/10-1/04/11 1/05/11 – 8/22/11 5/16/10 – 8/22/11
Student (Domestic) ❒ $1,295 ❒ $480 ❒ $815 ❒ $380
Spouse (Domestic) ❒ $2,490 ❒ $900 ❒ $1,590 ❒ $720
Child(ren) (Domestic) ❒ $1,335 ❒ $480 ❒ $850 ❒ $385
Payment Instructions: Make check or money order payable to Collegiate Risk Management in US dollars. Mail payment to:
Collegiate Risk Management, P.O. Box 850001, Orlando, FL 32885-0164. Your cancelled check is your only receipt. It is the stu-
dent’s responsibility for timely renewal payments. If you have questions please contact Collegiate Risk Management at 1-800-922-
Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application con-
taining any false, incomplete, or misleading information is guilty of a felony of the third degree.
IMPORTANT: Coverage will be effective: the date the correct premium is received by the Company or a representative of the
Company, or the effective date of the coverage period, whichever is later. By signing below, the student acknowledges the follow-
ing: (1) He/she has carefully read the plan description and elects to enroll as indicated on this enrollment card; (2) Rates are not
pro-rated other than as listed on this enrollment card; (3) He/she meets the eligibility requirements for this coverage as described
in the plan description; (4) If it is later determined that the student is not eligible, the premium will be refunded; and (5) Other than
eligibility, the premium is not refundable.
Signature of Student_________________________________________________ Date_________________________________
MLICENROLL.FL(UNIVERSITY OF NORTH FLORIDA 07-10) 17987717