2008/2009 HOSPITALIZATION / SICKNESS
INSURANCE ENROLLMENT REQUEST FORM

Campbell University : International Students Only
(Domestic Students must use separate enrollment form).

Important Notice:  Enrollment is only allowed during the open enrollment time period, which is 8/18/08 to 9/18/08.  Exceptions will be made for the following:

1.  Enrolling as a new or transfer student within 31 days of enrollment at the school; or,

2.  Within 31 days of ineligibility under another plan of Creditable Coverage.

After the initial enrollment period has lapsed, you must contact our office at 269.381.6630 for enrollment instructions.
STUDENT INFORMATION:
School Name:  
Student ID Number:*  
First Name:*  
Middle Initial:  
Last Name:*  
Home Country Address 1:*  
Home Country Address 2:  
City:*  
State / Province / County:*  
Postal Code:*  
Country:  
Home Phone Number:*  
Passport Number:*  
CAMPUS INFORMATION:
Campus Address 1:  
Campus Address 2:  
City:  
State:  
Zip Code:  
Campus Phone Number:  

By submitting this enrollment form, I verify that I am enrolled as a Campbell University student taking 12 or more credit hours*.  I request to be enrolled in the Campbell University accident and sickness health insurance plan for international students and I understand my student account will be billed the appropriate amount for the term of coverage selected.

Fall Enrollment:
(12 Months Coverage)		   Fall $900.00
Spring Term Enrollment:
(7 1/2 Months Coverage)		   Spring $600.00
   


*The company maintains the right to investigate student status and attendance records to verify that Policy eligibility requirements have been met.   Eligibility requirements must be met each time a premium has been paid to continue coverage.