Student Accident & Sickness Insurance Enrollment Form
Academic Year 2017 - 2018


Underwritten by:
National Guardian Life Insurance Company
Home Office: Madison, WI
Administrative Office: Consolidated Health Plans, Inc
2077 Roosevelt Ave, Springfield, MA 01104

Insurance Plan for Scholars and Scholar Dependents at Northwest Nazarene




Click here to view the Travel Guard

Click here to view the Nurseline Brochure

Click here to view a hard copy of the Enrollment Form


If you choose to enroll by mail, download the enrollment form above, complete the form and mail it with your payment to:
American Management Advisors/Aliverisk,
P.O. Box 366
Langhorne, PA 19047,
USA.
 

Please follow these steps if you would like to confirm your enrollment in the College sponsored health insurance plan for the 2017-2018 academic year.

Student Information

If you choose to enroll online, payment is required by credit card.
       To enroll online complete the form shown below.

      
Fields marked with an asterisk (*) must be filled in.
      At least one of the fields marked with a plus (+) must be filled in.

* First Name: 
* Last Name: 
Middle Name: 
* Date of Birth:   (mm/dd/yyyy)
+ Social Security:   (ex. 999-99-9999)
+ Student ID: 
* Gender: 
* Address: 
Address 2: 
* City: 
* State: 
* Zip Code: 
* Phone Number: 
* Email: 
Number of Dependents:
* Status: 

 

Dependent Information

  Name Soc. Sec. # Gender Birthdate
Spouse
Child
Child
Child

Coverage becomes effective on the later of: the Master Policy effective date 08-01-2017; the first day of the term for which the proper premium has been paid; or 12:01 A.M. following the date the proper premium is received by the University or Plan Administrator. All coverage expires on the earlier of: the Master Policy expiration date 07-31-2018, or when premium for the insurance coverage is due and unpaid. It is your responsibility to make timely premium payments regardless of whether or not you receive a premium notice.

All Premium rates are in USD and include an agent service fee. This plan has an enrollment period, refer to online brochure.
* Spring/Summer and Summer may be purchased by a new student not previously eligible to enroll for Annual or Fall coverage or a student who purchased Fall coverage and wishes to continue coverage.

PREMIUM RATE
  None Annual
08/01/2017
to
07/31/2018
Fall
08/01/2017
to
01/01/2018
*Spring/Summer
01/01/2018
to
07/31/2018
Spouse   $0.00 $1743.00 $731.00 $1012.00
Each Child   $0.00 $1743.00 $731.00 $1012.00



Refund Policy
No refunds, except as provided in the Master Policy.

Acknowledgement
I understand by applying for coverage I am agreeing to the eligibility requirements of enrollment as outlined in the brochure and important provisions above.

Electronic Signature

I have read and agree to the Terms and conditions and Privacy Policy. -- View Terms and Conditions -- View Privacy Policy

By checking this box and submitting this form I agree that all the above information above is true, complete, and accurate.

Other Questions, Comments, or Requests:(max 250 characters)
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All Rights Reserved. Phone - 215-946-8888