Enrollment Form
2011-2012
PLEASE
STEPHEN F. AUSTIN STATE UNIVERSITY
Study Abroad Injury and Illness Insurance
2593
PRINT - COMPLETE ALL INFORMATION
L AST N AME
MO.
D AY
D ATE
OF
F IRST N AME
Y EAR
B IRTH
S OC . S EC . N O .
M ALE
F EMALE
TELEPHONE N O .
M AILING A DDRESS
A PARTMENT N O .
CITY
S TATE
I want coverage to begin on
/
/
ZIP CODE
and terminate on
E-MAIL:
.
MONTHLY RATE
Study Abroad Participant
$ 31.00
Participant’s Spouse
$ 78.00
Participant’s Child
$ 39.00
Monthly Rate must be used for trips less than 4 weeks.
By my signature, I certify to the eligibility for insurance of the individuals named hereon.
Signature - Student - Parent - Guardian
.
PLEASE RETURN THIS ENROLLMENT FORM TO:
INES MAXIT
Study Abroad Coordinator
P. O. Box 6152, SFA
404 Aikman Drive, Liberal Arts North, Room 402
Nacogdoches, Texas 75962-6152
DEPENDENTS TO BE INSURED:
Spouse:
Date of Birth
Child:
Child:
Date of Birth
Date of Birth