Fillable Form 20192020: Enrollment Form Merritt College International Student (College of Alameda)

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Form 20192020: Enrollment Form Merritt College International Student (College of Alameda)

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Merritt College
International Student Insurance Plan
Enrollment Form
2019–2020
CA LICENSE NO. 0G55426, RELATION INSURANCE SERVICES
IF THERE ARE ANY DISCREPANCIES BETWEEN THIS DOCUMENT AND THE POLICY, THE POLICY WILL GOVERN.
Revised November 5, 2019 7:02 AM
/ 1 /
EDUCATION SOLUTIONS
Complete the information below. Please print clearly and answer all questions, then mail to the address listed below. Incomplete forms will not be
accepted. For questions about enrollment, please contact Relation Insurance Services at (800) 537-1777.
1. ENTER STUDENT INFORMATION:
STUDENT’S LAST NAME STUDENT’S FIRST NAME MI
STUDENT’S U.S. MAILING ADDRESS—NUMBER AND STREET NAME (OR P.O. BOX #) APT/UNIT #
CITY STATE ZIP
STUDENT’S DATE OF BIRTH (MM/DD/YYYY)
FEMALE
MALE
STUDENT’S PHONE NUMBER STUDENT’S SCHOOL ID NUMBER
STUDENT’S EMAIL ADDRESS
OK TO CONTACT
YOU VIA EMAIL?
YES
NO
ARE YOU AN
INTERNATIONAL
STUDENT?
YES
NO
IF YES, WHAT IS YOUR HOME COUNTRY OR COUNTRY OF REGULAR DOMICILE? PASSPORT VISA TYPE:
F1 J1 OTHER _________________________
2. SELECT THE COVERAGE YOU WISH TO PURCHASE AND CALCULATE THE TOTAL CHARGES:
(IF PURCHASING DEPENDENT COVERAGE, DEPENDENT COVERAGE PERIOD MUST BE THE SAME AS THE STUDENT’S COVERAGE PERIOD)
ANNUAL
12/31/2019 to 12/30/2020
SPRING/SUMMER
12/31/2019 to 07/31/2020
SUMMER
06/01/2020 to 07/31/2020
FALL
08/01/2020 to 12/30/2020
STUDENT
$ 1,506.00 $ 878.50 $ 251.00 $ 627.50
SPOUSE/DOMESTIC PARTNER
$ 4,156.20 $ 2,424.45 $ 692.70 $ 1,731.75
EACH CHILD
$ 2,077.80 $ 1,212.05 $ 346.30 $ 865.75
TOTAL AMOUNT DUE
= $ = $ = $ = $
The cost of coverage includes insurance premium and administrative fees.
3. IF ENROLLING DEPENDENTS, COMPLETE DEPENDENT INFORMATION ON PAGE 2 OF THIS FORM.
DEPENDENTS MAY BE ENROLLED IN THE PLAN ONLY IF THE STUDENT IS ALSO ENROLLED IN THE PLAN.
4. REMIT PAYMENT IN U.S. FUNDS ONLY. MAKE CHECK OR MONEY ORDER PAYABLE TO: RELATION INSURANCE SERVICES
OR COMPLETE CREDIT CARD INFORMATION BELOW.
CREDIT CARD AUTHORIZATION: CHARGE WILL APPEAR AS “STUDENT HEALTH INSURANCE, RELATION” ON YOUR CREDIT CARD BILL.
CREDIT CARD #
NAME OF CARDHOLDER (PLEASE PRINT)
CHARGE AMOUNT:
$
EXPIRATION DATE
________/________
By signing below, I authorize my credit card to be charged the amount listed above for the coverage I have selected under the
Merritt College International Student Insurance Plan.
SIGNATURE OF CARDHOLDER
5. STUDENT SIGNATURE:
I CERTIFY THAT I AM ENROLLED AT MERRITT COLLEGE. BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE INFORMATION
CONTAINED IN THE MERRITT COLLEGE INTERNATIONAL STUDENT INSURANCE PLAN POLICY AND ELECT TO ENROLL FOR THE COVERAGE SPECIFIED ABOVE.
SIGNATURE
_____________________________________________________________________________ DATE______________________________________
6. RETURN THIS FORM WITH PAYMENT TO: RELATION INSURANCE SERVICES, P.O. BOX 240042, LOS ANGELES, CA 90024
Enrollment Form (continued)
2019–2020
CA LICENSE NO. 0G55426, RELATION INSURANCE SERVICES
IF THERE ARE ANY DISCREPANCIES BETWEEN THIS DOCUMENT AND THE POLICY, THE POLICY WILL GOVERN.
/ 2 /
IF ENROLLING DEPENDENTS, COMPLETE DEPENDENT INFORMATION BELOW:
LAST NAME FIRST NAME MI
DATE OF BIRTH
(MM/DD/YYYY)
GENDER
SPOUSE/DOMESTIC PARTNER
FEMALE
MALE
CHILD
FEMALE
MALE
CHILD
FEMALE
MALE
CHILD
FEMALE
MALE
CHILD
FEMALE
MALE
DEPENDENTS MAY BE ENROLLED IN THE PLAN ONLY IF THE STUDENT IS ALSO ENROLLED IN THE PLAN. Dependents must be enrolled on the date the student
enrolls or within 31 days of marriage, birth, adoption or placement for adoption, arrival in the U.S., or ineligibility under another creditable coverage.
Newly acquired dependents (spouse and/or children) are not subject to the enrollment deadline dates. However, enrollment and premium payment for all newly
acquired dependents (spouse and/or children) must be submitted within 31 days of marriage, birth, adoption or placement for adoption, or arrival in the U.S. (Proof
of date of arrival in the U.S., birth, adoption, or marriage may be requested). Otherwise, enrollment cannot be accepted after the enrollment deadline dates.
No-Cost Language Assistance Services:
You are eligible to access the services of an interpreter to have insurance documents read to you in your native or preferred language, at no cost to you.
To use this free service, call the number listed on your insurance ID card or (800) 468-4343. For further help, call the CA Department of Insurance at
(800) 927-4357.
EDUCATION SOLUTIONS
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Form 20192020: Enrollment Form Merritt College International Student (College of Alameda)

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Completed 3 September 2020

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