2006 - 2007 NORTHERN KENTUCKY UNIVERSITY
Student Enrollment Form
(Please Print)

Student:  ____________________________________
Last Name First Name MI
Date Of Birth: __/__/__ Sex ____ SS# __________ Telephone

 

 ___________
Address: ___________________________________
  Street City State Zip Code
Email Address _________________________________

 

Please Check Appropriate Box Annual Fall Semester Spring Semester Summer Semester
  8/14/06 to 8/14/07
Annual Base Plan		 8/14/06 to 1/4/07
1st Semester Base Plan		 1/4/07 to 5/8/07
2nd Semester
Base Plan		 5/8/07 to
8/14/07
Summer Base Plan
Student $510.00 $185.00 $185.00 $140.00
Student & Spouse $1,850.00 $669.00 $669.00 $520.00
Student, Spouse & Child(ren) $2,881.00 $1,059.00 $1,059.00 $825.00
Student & Child(ren) $1,542.00 $573.00 $573.00 $444.00

 

Please mark method of payment and list dependents names (if insuring dependents) of the reverse side of this form.

Students purchasing coverage by Semester must submit another enrollment form to renew coverage for each Semester. In order to maintain continuous coverage, payment must be received prior to the start date of each Semester. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits application or files a claim containing a false deceptive statement may be guilty of insurance fraud.

LIST OF DEPENDENTS
(Please Print)

I wish to extend my own coverage to include my following dependents (spouse and unmarried children under age 19)

Dependent's Name SS# Date Of Birth Relationship to Student
__________________ ___-__-____ __/__/__ _______________
__________________ ___-__-____ __/__/__ _______________
__________________ ___-__-____ __/__/__ _______________
 

 

METHOD OF PAYMENT (must be filled out and signed in order to process enrollment)

Make Check or Money Order Payable to Bollinger, Inc.
Student's Signature ______________________________________________________
I hereby authorize that you charge my credit card:  Visa Master Card
Expiration Date
Month:
Year:  		Card No.

 

Card Holder's Signature: __________________________________

Mail this form and payment to: Bollinger Inc. 101 JFK Parkway, Short Hills, NJ 07078, Attn: College Dept. Coverage becomes effective on August 14, 2006 or date following the postmark on the envelope containing your payment, whichever last occurs, and will continue during the period for which the premium has been paid.