SUNY Upstate Medical University

2015/2016 Enrollment Application Dependents of All SUNY Upstate Dependent

In order to enroll you must complete steps 1 through 5!

1.  Complete all Student information. Incomplete information will delay processing! Contact Aetna at (855) 546-5421 for assistance.

Student Name: ______

Last Name First Name MI

Student ID # ______Email Address: ______

Mailing Address: ______

City: ______State: ______Zip Code: ______

Phone Number: ______Date of Birth: ______Sex: Male Female

mm/dd/yy

2.  List Dependents to be insured. Dependent coverage is only available if the student is covered.

Dependents Last Name First Name DOB M/F

Spouse
Child
Child

3.  Select Enrollment Plan

Form ID: 867883-A18

/
A.
/
B.
Basic Plan / Annual
Insurance Rate
08/01/2015-07/31/16 / *Annual Plan - Installment Option
Insurance Rate
08/01/15-07/31/16
Deadline: 08/30/15 / Deadline: 08/30/15 then 01/31/16
*The medical plan allows dependents to pay for their health insurance in two installments, see deadline dates above. Please note that your student account will be automatically charged for the second installment if not paid in full by the deadline date. The charges below are per installment.
Spouse / ¨ $6,327.00 / ¨ $3,163.50
One Child / ¨ $6,327.00 / ¨ $3,163.50
Two or More Children / ¨ $12,654.00 / ¨ $6,327.00

4.  Select Your Payment Method (Cash is not Accepted).

 Check or Money Order: Make check or money order payable to AETNA STUDENT HEALTH.

 Credit Card: Refer to the charge card authorization to charge premium to Visa, MasterCard, Discover or American Express.

Charge Full Amount: $ .

Credit Card Number: Expiration Date: /

Signature of Cardholder:______
Printed Name and Address (if different from student):

5.  Notice to Student (Signature required)

I have carefully read the policy plan provisions including all enrollment guidelines and elect to enroll as indicated above. I permit SUNY Upstate Medical University to provide Aetna Student Health with enrollment status for purposes of eligibility under this plan. I warrant that the information I have provided on this application form is true and I am aware that if I provide false information, coverage for my spouse and child(ren) can be made void. I understand that if it is later determined that I am not eligible (see the Plan Design and Summary of Benefits), the premium will be refunded, but the premium is not refundable for reasons other than eligibility.

It is the student’s responsibility for timely renewal payments.

Enrollment Guidelines: For applications received and accepted after the effective date of the policy period, but before the established deadline, coverage will be effective the first date of that policy period. Applications received after the deadline will not be accepted, unless there is a significant life change that directly affects applicant’s insurance coverage. When applying due to a life event, please attach appropriate documentation providing proof and date of the event. If you have questions regarding this coverage, please call Aetna Student Health at (855) 546-5421.

Fully insured student health insurance plans are underwritten by Aetna Life Insurance Company. Self-insured plans are funded by the applicable school, with claims administration services provided by Aetna Life Insurance Company. Aetna Student HealthSM is the brand name for products and services provided by Aetna Life Insurance Company and its applicable affiliated companies (Aetna).

Signature: ______Date: ______

If paying by CHECK: MAIL TO: Aetna Student Health P.O. Box 14388, Lexington, KY 40512

Or

If paying by CREDIT CARD: FAX TO Aetna Student Health Enrollment at: 1-859-425-5200