PART-TIME AND DEPENDENT INSURANCE ENROLLMENT CARD COMPLETE THIS FORM ONLY IF YOU ARE A PART-TIME STUDENT APPLYING FOR INDIVIDUAL OR INDIVIDUAL AND DEPENDENT COVERAGE OR A FULL-TIME STUDENT ADDING DEPENDENT COVERAGE ONLY

(PLEASE PRINT)
Student's Name________________________/_______________________/___________________
                                         Last                                              First                                                  MI

Permanent US Address____________________________________________________________
                                             Street or PO Box                   City                                 State           Zip   

Social Security #_________________   Date of Birth____________  Phone # (    )____________

Expected Graduation Date:__________/__________
                                            Month               Year

List Dependents to be insured below. Dependent coverage is available only if the student is also insured under this plan.

NOTE: Please remit payment directly to Bollinger Inc. 101 JFK Parkway, Short Hills, New Jersey 07078

PLEASE CHECK ALL APPROPRIATE BOXES:

(A) Full-Time Undergraduate (Dependents)

(B) Part-Time Undergraduate (Student or Dependent)

Students may purchase optional coverage for themselves or for themselves and all family members.

NOTICE TO STUDENT:  Coverage will be effective the date the correct premium is received by the Company or a representative of the Company or the effective date of the coverage period, whichever is later, unless otherwise stated in the Master Policy. It is the student’s responsibility for timely renewal payments. By signing below, the student acknowledges the following: 1) He/She has carefully read the brochure and elects to enroll as indicated on this enrollment card; 2) Rates are not pro-rated other than as listed on this enrollment card; 3) He/She meets the eligibility requirements for this coverage as described in the brochure; 4) If it is later determined that the student is not eligible, the premium will be refunded; and 5) Other than for ineligibility, the premium is not refundable.

METHOD OF PAYMENT Enclosed is my check (Make check payable to BOLLINGER) I hereby authorize that you charge my credit card     VISA     MASTERCARD Credit Card No.    Expiration Date:   Month      Year   Cardholder name: (Printed)__________________________________________ Cardholder Signature:__________________________________________  Date___________________