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Aetna Life Insurance Company

Aetna Student Health

Syracuse University-Student and Dependent Insurance Plan 2011/2012 Student Health Insurance Enrollment Form

In order to enroll you must complete steps 1 through 5!

1. Complete all Student information. Incomplete information will delay processing! Contact Aetna Student Health at 866-746-6590 for assistance.

APPLICATIONS WITH MISSING INFORMATION WILL NOT BE PROCESSED.

Student Name:

Last Name

First Name

MI

Student ID:

Email Address: Mailing Address:

This address will be used for all Aetna Student Health insurance communications

Apt.#

City: State: Zip Code:

Phone Number: - - Date of Birth: / / Sex: Male Female mm/dd/yy SU E.S.F
Phone Number: - -
Date of Birth: / /
Sex: Male
Female
mm/dd/yy
SU
E.S.F
Graduate
Undergraduate
2. List Dependents to be insured. Dependent coverage is only available if the student is covered.
Dependents
Last Name
First Name
DOB
Social Security Number
M/F
Spouse/
Domestic
Partner
Child
Child
Child
Child

3. Select Enrollment Plan

Form ID:

A.

474908-SPR14-1

 

Monthly Installment Option for Annual

Effective Date:

1/1/12-7/31/12

Deadline Date: 2/1/12

1.Student

$540 for 1 st and 2 nd month payment, $270 per month thereafter

2.

Student

$1,104 for 1 st and 2 nd month payment, $552 per month thereafter

Plus One

3.

Family

$1,672 for 1 st and 2 nd month payment, $836 per month thereafter

PLEASE COMPLETE AND SIGN THE BOTTOM OF THIS FORM. APPLICATIONS WITH MISSING INFORMATION WILL NOT BE PROCESSED. WITHOUT YOUR SIGNATURE, WE WILL NOT ACCEPT YOUR ENROLLMENT APPLICATION.

4. Designate Payment Method. Make check or money order payable to Aetna Student Health or refer to the charge card authorization to charge premium to Visa or MasterCard (Please note Visa and MasterCard are the only credit cards accepted). CASH WILL NOT BE ACCEPTED.

CREDIT CARD AUTHORIZATION-PLEASE PRINT CLEARLY!!! (VISA OR MASTERCARD ARE THE ONLY ACCEPTED CREDIT CARDS)

Charge full amount: $ .

Credit Card# (Visa or MasterCard only): Exp. Date: /

Signature of Cardholder:

Printed Name and Address(if different from student):

5. Please indicate which payment option you select:

Students will have several payment options under the Student Health Insurance Plan, including:

Annual payment can be made online with a credit card, or the student can mail the paper application with check.

Monthly payment of installments by auto-debit to credit card; (you will need to complete a paper application and remit to Aetna Student Health at the address stated below)

Monthly payment option is only available when paying by credit card.

Your signature provides authorization to charge your credit card for the 1 st and 2 nd payments ($540 for single student payment) at the time of application and continued monthly debits for the remainder of the policy year.

This is an annual commitment. Electing the monthly payment option requires you to pay each monthly payment through out the policy year.

If for any reason your credit card does not accept the monthly debit, an alternate credit card must be provided to insure payment and remain covered.

If a credit card expires or needs to be changed, a change of credit card information form is available by calling Aetna Student Health Customer Service at 1-866-746-6590.

5. Notice to Student (Signature required)

I have carefully read the policy plan provisions including all enrollment guidelines and elect to enroll as indicated above. I permit Syracuse University to provide Aetna Student Health with enrollment status for purposes of eligibility under this plan. I warrant that the information I have provided on this application form is true and I am aware that if I provide false information, my coverage, and coverage for my spouse and child(ren) can be made void. I understand that if it is later determined that I am not eligible (see the brochure, pamphlet or Master Policy for eligibility guidelines), the premium will be refunded, but the premium is not refundable for reasons other than eligibility.

It is the student’s responsibility for timely renewal payments.

*Enrollment Guidelines: For applications received and accepted after the effective date of the policy period, but before the established deadline, coverage will be effective the first date of that policy period. Applications received after the deadline will not be accepted, unless there is a significant life change that directly affects applicant’s insurance coverage. When applying due to a life event, please attach appropriate documentation providing proof and date of the event.

Signature:

Date:

ENCLOSE PAYMENT WITH ENROLLMENT FORM & MAIL TO:

AETNA STUDENT HEALTH BENEFIT P.O. BOX 15706, BOSTON, MA 02215-0014