INTERNATIONAL COMMUNITY SERVICE
Enrollment Form For Student / Scholar Accident & Health Insurance
2007-2008
(Effective Date must be between 08/01/2007 and 07/31/2008 and Coverage canNOT extend beyond 10/31/2008)
NOTE -
Failure To Provide All Required Information May Delay Or Void Your Insurance
Principal (Student/Scholar) Information:
Last_Name
First_Name
MI
Address
City
State
Zip
StudentID
(SSN)
Gender
Male
Female
BirthDate
Select
01
02
03
04
05
06
07
08
09
10
11
12
Month(MM)
Select
01
02
03
04
05
06
07
08
09
10
11
12
13
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24
25
26
27
28
29
30
31
Day(DD)
Year(YYYY)
WorkPhone
HomePhone
Fax
Email
Coverage Information:
This is a
New Application
Renewal
I am a
Student
Scholar
ICS Member
Visa Type
F-1 visa
J-1 visa
H-1 visa
Other (specify)
Specify
"Other"
Visa Type
School
HomeCountry
Plan
ICS Plan A
Vantage Plan
Discount Plan
Coverage Period
Annual (12 months)
11 months
10 months
9 months
8 months
7 months
6 months
5 months
4 months
3 months (Minimum)
Start Coverage on
Select
01
02
03
04
05
06
07
08
09
10
11
12
Month(MM)
Select
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day(DD)
Year(YYYY)
(Coverage canNOT begin earlier than the day after successful application)
Dependents To Be Insured:
Do Not
put anything in the boxes
if
you are not insuring Dependent(s)
Spouse
Male
Female
SpouseBirthDate
Select
01
02
03
04
05
06
07
08
09
10
11
12
Month(MM)
Select
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day(DD)
Year(YYYY)
Children:
Name(Last/First)
Gender
BirthDate(mm-dd-yyyy)
Child1
Male
Female
Child2
Male
Female
Child3
Male
Female
Credit Card Payment Authorization:
Card Type
Visa
MasterCard
Discover
AmericanExpress
Card Number
Holder Name
Expiration Date
Student/Scholar Age
Spouse Age (if to be insured)
Total Premium To Be Charged
$
Check Rates
Comments
(if any) -
No more than 3 lines
:
To submit, please click
Review
, then click
Submit
on the review page
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