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International Community Service
Enrollment Form for Student/Scholar Accident
& Health Insurance
2007-2008
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Please Print All Applicable Information Clearly
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Failure to do so may delay or void your insurance
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[Please refer
to ICS brochures for Policy details]
Last Name: Lovely
First Name & MI:
Guy J.
Address: 1001 NW 1000
STREET, #100A
City: Great Land
State & Zip: XX
32614-0000
Social Security No. (or Student ID):
123-45-6789
Date of Birth (mm/dd/yyyy):
01/22/68
Gender (Male or Female):
Male
Telephone (include area code):
(123) 456-7890
Fax (include area code):
(123) 456-7891
Email: good@health.com
Status (Student, Scholar, or ICS Member):
Student
Visa Type (F-1, J-1, etc.):
F-1
School Advisor's Name (Last/First):
Dr. Who, Boss
College or University Attending:
University of World
CIN # (leave blank if unknown):
xxxx
Home Country (Country of Origin):
India
Indicate Period/Coverage Selected -
Period (Annual; 11, 10, ... 3 Months Minimum):
3 months
Plan (Plan A, Vantage Plan, Discount Plan, etc.):
Plan A
Desired Starting Date (mm/dd/yyyy):
08/08/2007
Specify "New Application" or "Renewal":
New Application
List All Dependent(s) To Be Insured -
Spouse Name (Last/First):
Lovely, Wife
Spouse Birth Date (mm/dd/yyyy):
01/20/1980
Spouse Gender (Male or Female):
Female
Child_1 Name (Last/First):
Lovely, Daughter
Child_1 Birth Date (mm/dd/yyyy):
08/28/2004
Child_1 Gender (Male or Female):
Female
Child_2 Name (Last/First):
Lovely, Son
Child_2 Birth Date (mm/dd/yyyy):
03/16/2006
Child_2 Gender (Male or Female):
Male
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):
Visa
Cardholder's Name (Last/First):
Lovely, Guy J.
Card No.: 4111-1111-1111-1111
Card Expiration Date (mo/yr):
10/06 [or] 10/2006
Total Premium to be charged:
$ 1,758.00
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