Enrollment Form For Voluntary Students And Their Dependents
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UNITEDHEALTHCARE INSURANCE COMPANY
ENROLLMENT FORM FOR VOLUNTARY STUDENTS AND THEIR DEPENDENTS
KENNESAW STATE UNIVERSITY
2015-599-1
PRIMARY INSURED
COMPLETE INFORMATION BELOW FOR STUDENT.
SOCIAL SECURITY #:
STUDENT ID #:
LAST (FAMILY) NAME:
FIRST (GIVEN) NAME:
MIDDLE INITIAL:
GENDER:
DATE OF BIRTH:
EXPECTED DATE OF GRADUATION:
MALE
FEMALE
(MONTH/DAY/YEAR)
(MONTH/YEAR)
PERMANENT U.S. ADDRESS: (HOUSE/BUILDING # AND STREET NAME)
CITY:
STATE:
ZIP CODE:
TELEPHONE #:
EMAIL ADDRESS:
DEPENDENT INFORMATION
Complete information below for Dependents to be insured. Dependent coverage is only available for Students insured under the
Plan (Please include a blank sheet for additional Dependents).
SPOUSE SOCIAL
GENDER:
DATE OF BIRTH:
SECURITY #:
MALE
FEMALE
(MONTH/DAY/YEAR)
First (Given) Name:
Middle Initial:
Last (Family) Name:
CHILD SOCIAL
GENDER:
DATE OF BIRTH:
SECURITY #:
MALE
FEMALE
(MONTH/DAY/YEAR)
First (Given) Name:
Middle Initial:
Last (Family) Name:
CHILD SOCIAL
GENDER:
DATE OF BIRTH:
SECURITY #:
MALE
FEMALE
(MONTH/DAY/YEAR)
First (Given) Name:
Middle Initial:
Last (Family) Name:
CHILD SOCIAL
GENDER:
DATE OF BIRTH:
SECURITY #:
MALE
FEMALE
(MONTH/DAY/YEAR)
First (Given) Name:
Middle Initial:
Last (Family) Name:
CHILD SOCIAL
GENDER:
DATE OF BIRTH:
SECURITY #:
MALE
FEMALE
(MONTH/DAY/YEAR)
First (Given) Name:
Middle Initial:
Last (Family) Name:
NOTICE TO STUDENT: Coverage will be effective the date the correct premium is received by the Company or a representative of the Company or
the effective date of the coverage period, whichever is later, unless otherwise stated in the Master Policy. 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.
NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim containing any false,
incomplete, or misleading information may be subject to criminal and/or civil penalties.
Student’s Signature: _____________________________________________________________
Date: ________________
EF-2014
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