Continuation Of Enrollment Form For Full Time Students And Their Dependents printable pdf download

RUTGERS UNIVERSITY

CONTINUATION OF ENROLLMENT FORM FOR FULL TIME STUDENTS

AND THEIR DEPENDENTS

Eligibility: All Insured Persons who have been continuously insured under the school's regular student Policy for at least

3 consecutive months and who no longer meet the Eligibility requirements under that Policy is eligible to continue their

coverage for a period of not more than 90 days under the school's policy in effect at the time of such continuation. If an

Insured Person is still eligible for continuation at the beginning of the next Policy Year, the insured must purchase

coverage under the new policy as chosen by the school. Coverage under the new policy 2016-519-2 is subject to the rates

and benefits selected by the school for that policy year.

Student’s Name____________________________Date of Birth:____________Rutgers RUID#:____________________

Address:________________________________________City:___________________State:_____Zip:______________

Email:__________________________________________

If you are enrolling Dependents, list Dependents to be insured below.

Dependent coverage is available ONLY if the student is also insured under the Plan.

Last Name

First Name

Date of Birth

Gender

Spouse:

Child:

Please check the period of coverage desired:

Period of Coverage

Student Only

Spouse

One Child

Two or More

Spouse and Two

Children

or More

Children

1 Month – 8/15/16 – 9/14/16

______ $163.59

______ $327.18

______

$490.77

2 Months – 8/15/16 – 10/14/16

______ $327.18

______ $654.36

______

$981.54

3 Months – 8/15/16 – 11/14/16

______ $490.77

______ $981.54

______

$1,472.31

*PLEASE NOTE: The Continuation Privilege will allow you to purchase up to a maximum of 3 consecutive months, but

not longer than the current plan year. Include full payment based on the coverage selected and the number of months chosen.

Payment will not be accepted on a month-to-month basis. Incorrect payment amounts will be returned and no coverage

will be in effect.

Make your check or money order for the total applicable premium listed above payable to University Health Plans.

Please return this form along with payment to:

University Health Plans, Inc.

One Batterymarch Park

Quincy, MA 02169

NOTICE TO STUDENT: Coverage is effective immediately following the expiration of the regular student plan and

must be purchased within 31 days after the expiration date of your student coverage. If premium is not received within 31

days, the premium will be refunded. By signing, the student acknowledges the following: 1) He/She has carefully read the

brochure 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 brochure; and 4) If it is

later determined that the student is not eligible, the premium will be refunded. Premium will not be refunded except for

ineligibility or entrance into the armed forces. Any person who includes any false or misleading information on an

application for an insurance policy is subject to criminal and civil penalties.

STUDENT'S SIGNATURE:_______________________________________________ DATE:___________________

Continuation Of Enrollment Form For Full Time Students And Their Dependents

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