2015-2016 Qualifying Event Enrollment Form

ANNA MARIA COLLEGE STUDENT HEALTH INSURANCE PLAN
Blue Cross Blue Shield – Blue Care Elect Preferred PPO Plan
2015-2016 Qualifying Event Enrollment Form
If you waived the Anna Maria College Student Health Plan for the 2015-2016 Policy Year and your other
insurance has terminated, you may use this form to enroll in the Student Health Plan due to your
Qualifying Event.
STUDENT INFORMATION:
Student ID____________ Last Name___________________________ First Name______________________
MI___ Gender___
Date of Birth___ /___ /______ Email Address_______________________________________ Phone #______ -______ - _______
Address___________________________________________________________________________________________________
City_______________________________________________________________ State_______ Zip Code___________________
Last Date of Prior Insurance Coverage __________________
REQUIRED INSURANCE DOCUMENTATION: When sending this enrollment form, you must include a
copy of a letter or certificate from your other insurance company that clearly indicates your name and the
date that your plan ended or will be ending.
EFFECTIVE DATE: When enrolling due to a Qualifying Event, the Student Health Plan will be made
effective as of the first date you became or will become uninsured.
PAYMENT: The health insurance premium will be added to your student account after the enrollment
form and appropriate documentation is received. To find out the amount that will be added to your
student account, please contact University Health Plans at 1-800-437-6448.
DEADLINE: University Health Plans must receive your completed enrollment form and the required
insurance documentation by the 60th day following the date of your other insurance plan’s
termination. Example: If your other insurance plan terminates on 11/30/15, University Health Plans
must receive all enrollment items by 1/31/16.
DELIVERY INSTRUCTIONS: Please return the form by e-mail to [email protected], by fax to
617-472-6419, or mail to University Health Plans at One Batterymarch Park, Quincy, MA 02169. You will
receive an insurance card approximately 10 business days after your enrollment items are received.
By signing below, you are requesting that Anna Maria College enrolls you in the Student Health Plan and are authorizing your
university to add the insurance premium amount to your student account. You will be responsible for paying the premium to your
College. To be eligible for this plan, you must be a student and you must attend classes for the 30 days following the termination
date of your other insurance coverage. Your College will verify your enrollment eligibility.
Student Signature:
Date: