Student Accident & Sickness Insurance Enrollment Form
Academic Year 2018 - 2019


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 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 2018-2019 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 08-01-2018; 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 07-31-2019, 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
08/01/2018
to
07/31/2019
Fall
08/01/2018
to
12/31/2018
*Spring/Summer
01/01/2019
to
07/31/2019
Student   $0.00 $1773.00 $743.00 $1030.00
Spouse   $0.00 $1773.00 $743.00 $1030.00
Each Child   $0.00 $1773.00 $743.00 $1030.00



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