| HOW
TO APPLY |
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| ONLINE
ENROLLMENT |
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| 1.
Select Online Enrollment Form from Menu Bar at Left |
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| 2.
Complete Enrollment Form and Submit Information |
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| 3.
Premiums can only be charged by credit card (VISA or
MasterCard) |
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| 4.
No forms or payment need to be mailed |
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| MEMBERS
WHO DO NOT
WISH TO ENROLL ONLINE |
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| 1.
Determine Method of Payment |
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□
Credit Card |
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(Premiums
billed monthly to your MasterCard or VISA) |
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Check-O-Matic |
(Premiums
deducted monthly from your checking account) |
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| 2.
Complete and Sign the Enrollment form.
Applicants who choose the Credit Card or |
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Check-O-Matic
method of payment must also complete the Monthly Automatic |
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Enrollment Form. |
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| 3.
To determine the premium payment, refer to the Premium rates
and use this |
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worksheet: |
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Medical
Premium |
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$________________ |
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Optional
Vision Program |
$________________ |
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Option
Dental Program |
$________________ |
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Total
Monthly Premium Due |
$________________ |
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| Applicants
Who Wish Monthly Premiums Charged to a Credit Card |
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| 1.
Complete the Enrollment Form and Monthly Automatic Enrollment
Form. |
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| 2.
Do not send any payment - premium will be charged to your
MasterCard or VISA |
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Credit Card. |
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| 3.
You can enroll online utilizing the Online Enrollment Form
from the menu at the left. |
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| Applicants
Who Wish Monthly
Premiums Debited From a Checking Account |
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| 1.
Complete the Enrollment Form and Monthly Automatic Enrollment
Form. |
| 2.
Send 2 checks; 1st check equal to the monthly payment payable
to Mass |
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Marketing
Insurance Consultants, Inc., and the 2nd check marked
"VOID" |
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and unsigned. |
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| Send
enrollment form, check(s) and Monthly Automatic Pay Plan form |
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applicable), to: |
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| SOMA
College Health Insurance Plan |
| P.O.
Box 95 |
| Orland
Park, IL 60462 |
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| FOR
YOUR CONVENIENCE, ONLINE ENROLLMENT IS AVAILABLE |
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MENU BAR AT LEFT |
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| Questions?
Call Toll-Free (800) 349-1039 |
| 8:00
A.M. - 5:00 P.M. |
| Central
Standard Time |
