International Community Service
Enrollment Form for Student/Scholar Accident & Health Insurance
2007-2008
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Please Print All Applicable Information Clearly -
Failure to do so may delay or void your insurance
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[Please refer to ICS brochures for Policy details]

Last Name:
First Name & MI:
Address:
City:
State & Zip:
Social Security No. (or Student ID):
Date of Birth (mm/dd/yyyy):
Gender (Male or Female):
Telephone (include area code):
Fax (include area code):
Email:

Status (Student, Scholar, or ICS Member):
Visa Type (F-1, J-1, etc.):
School Advisor's Name (Last/First):
College or University Attending:
CIN # (leave blank if unknown):
Home Country (Country of Origin):

Indicate Period/Coverage Selected -
Period (Annual; 11, 10, ... 3 Months Minimum):
Plan (Plan A, Vantage Plan, Discount Plan, etc.):
Desired Starting Date (mm/dd/yyyy):
Specify "New Application" or "Renewal":

List All Dependent(s) To Be Insured -
Spouse Name (Last/First):
Spouse Birth Date (mm/dd/yyyy):
Spouse Gender (Male or Female):
Child_1 Name (Last/First):
Child_1 Birth Date (mm/dd/yyyy):
Child_1 Gender (Male or Female):
Child_2 Name (Last/First):
Child_2 Birth Date (mm/dd/yyyy):
Child_2 Gender (Male or Female):
Child_3 Name (Last/First):
Child_3 Birth Date (mm/dd/yyyy):
Child_3 Gender (Male or Female):

Credit Card Payment Authorization - **
Card Type (MasterCard/VISA/Discover/American Express):
Cardholder's Name (Last/First):
Card No.:
Card Expiration Date (mo/yr):
Total Premium to be charged: $

**If paying by check or money order, you must mail completed 
enrollment form together with required premium (payable to 
United HealthCare Insurance Company) to:

Insurance for Students
600 Corporate Drive, Suite 101
Ft. Lauderdale, FL 33334
Toll-Free: 1-800-356-1235
Fax: 1-954-772-0872