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University of North Florida 2010-2011

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					                                        University of North Florida 2010-2011
                                   Domestic Student Health Insurance Enrollment Form
                                                     (Please Print)


 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:
                                                               Yes    No

 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
                                                                                                                   (mm/dd/yy)

 Spouse

 Child

 Child

 Child


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-
3420.

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