University of the Cumberlands | Student Insurance

UNIVERSITY OF THE CUMBERLANDS
2013-2014 VOLUNTARY ACCEPTANCE OF STUDENT INSURANCE

Student Information

Student's First Name

Student's Middle Name

Student's Last Name

/ /

Student's Birthdate

Student ID #

Student's SSN (Internationals use UC ID)

Student's Address - This is where your Insurance ID Card will be mailed

City

State

Zip

( ) -

Email Address

Primary Phone Number

Secondary Phone Number

Is this student participating in intercollegiate sports at UC? Yes No

Verification and Submission

I request to be added to UC's student insurance program for the 2013 Fall term. I understand that my voluntary enrollment in this program is subject to the eligibility requirements of the insurance company, and if approved to be insured, a premium charge of $525 will be charged to my Cumberlands' student tuition account. The signature of a parent or guardian is required if the student is under age 18.

Student Signature

Parent Signature (if applicable)

Date

UNIVERSITY OF THE CUMBERLANDS 2013-2014 VOLUNTARY ACCEPTANCE OF STUDENT INSURANCE

UNIVERSITY OF THE CUMBERLANDS
2013-2014 VOLUNTARY ACCEPTANCE OF STUDENT INSURANCE