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Markel Insurance Company P.O. Box 79652 Baltimore MD 21279-0652

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Markel Insurance Company P.O. Box 79652 Baltimore MD 21279-0652 Powered By Docstoc
					                    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
Student
                                                                                                     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.




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posted:9/2/2011
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