INCREASED SUPPLEMENTAL LIMIT ENROLLMENT FORM FOR AgNES SCOTT COLLEgE
Student Name: ________________________________________________________________________ Telephone No. (_______) ______________________
Student Address: ___________________________________________________ City: ___________________________ State: ______ Zip: ___________
Student Date of Birth: - - Student Social Security Number: - -
Premium enclosed: $519 for student under age 25 Amount enclosed: $__________ Check or money order number: _________
$785 for student age 25 or over Make check or money order payable to Markel Insurance Company.
This completed form and payment must be received by us prior to: 08/15/11
I hereby certify that as the full-time student applicant named above, the information Mail to:
contained on this enrollment is true. I understand that the effective date of my
coverage under the Increased Supplemental Limit is the same as under my basic plan.
Markel Insurance Company
P.O. Box 79652
Signature: _____________________________________ Date: ____/____/____ Baltimore MD 21279-0652
IMPORTANT: Injury resulting from practice or play of intercollegiate sports is excluded from this plan.