I have carefully read the brochure and elect to enroll as indicated. Rates are not pro-rated other than as listed. I authorize the university to provide Aetna Student Health with my enrollment status to validate eligibility under the Plan. I warrant that the information I have provided in this application is true and accurate. If it is later determined that I have provided inaccurate information, my coverage and the coverage of my dependent(s) may be voided. I understand that premium will be refunded in the event that I am later determined to be an ineligible student. In such an event, I agree that my return premium may be reduced by the amount of any paid claims. Premium is not refundable for any reason other than a determination of ineligibility.

Enrollment Guidelines: Please refer to your school insurance plan brochure for your enrollment effective date. Applications will not be accepted after the enrollment deadline.