University of Central Florida Student Health Insurance Plan

2013-2014 CMMS Intensive English Program Dependent Enrollment Form (Please Print) Student Name______________________ ________________________________ _______________________________ Last First Initial Home Address_____________________________ ____________________________ ____________ _________________ Street City State Zip Code Student ID #_________________________ Male______ Female________ Date of Birth _____/_____/_______ MM DD YYYY Phone Number____________________________ Email Address _____________________________________________ STUDENT ENROLLMENT Please circle selected coverage.

Dates of Coverage

Spring 1 (1/1/14 2/19/14)

Spring 2 (2/20/14 4/23/14)

Summer 1 (4/24/14 6/11/14)

Summer 2 (6/12/14 8/14/14)

Enrollment Deadline

January 31, 2014 March 15, 2014 May 15, 2014 July 15, 2014

Spouse/Domestic Partner

$868 $868 $868 $868

Each Child $526 $526 $526 $526 Processing Fee 10.00 Total Payment

Please Note: Enrollment Forms will not be accepted after these deadlines Dependent coverage is available only when the student is also insured under this plan and cannot exceed coverage purchased by the student. Enrollment forms must be submitted within the designated deadline for the requested coverage period. In the event of a qualifying event (i.e. birth of child, marriage, etc.), this Dependent Enrollment form and payment must be received by Gallagher Koster within 31 days of the qualifying event. There is no pro-ration of the premium. Once a dependent is enrolled, coverage cannot be terminated unless the student loses eligibility. List Dependent(s) to be insured below:

Notice to Students: Coverage will be effective the first date of the Coverage Period when the correct premium is received by Gallagher Koster by the Enrollment Deadline; Enrollment Forms will not be accepted after the Enrollment Deadline has passed. It is the students responsibility for timely renewal payment. By signing below, the student acknowledges the following: 1) He/She has carefully read the brochure and elects to enroll as indicated on this enrollment form. 2) Rates are not prorated other than as listed on this enrollment form. 3) Enrolled Student meets the eligibility requirements for this coverage as described in the brochure. 4) If it is later determined that the student is not eligible, the premium will be refunded. 5) Other than for eligibility reasons, the premium is not refundable. Signature of Student: ________________________________________________ Date: _____________ PAYMENT INSTRUCTIONS: Charge to my (check one): ___ Visa ___ Master Card Card Number: ____________________________ Amount Charged: $_____________ Expiration Date: ______________ Print Name and Address of Card holder_______________________ ___________________________________________ Check or money order (International checks are not accepted) Make check or money order payable to Gallagher Koster. Mail enrollment form along with premium payment to:

Gallagher Koster P.O. Box 845663

Boston MA 02284-5663 Fax: 617-479-0860

Phone:1-877-535-3127

First Name M. I. Last Name Gender Date of Birth Spouse Child Child Child

University of Central Florida Student Health Insurance Plan2013-2014 CMMS Intensive English Program Dependent Enrollment FormStudent EnrollmenT Please circle selected coverage.