SOMA College Health Insurance Plan

Please use this form to fill out an application online. Enrollment online is only available to applicants who chargeinsurance premiums to a credit card (Master Card/VISA).
Applicant Name
Address
City, State, Zip
School
Date of Birth
S.S.#
Sex		Male Female
Marital Status		Single Married Divorced Widowed
Telephone Number
E-Mail Address
Medical Plan Selected		Plan 1 Plan 2
Do you wish to enroll in the optional Dental/Vision plan?		Yes No

Dependent Information (if applicable):
A.) Spouse		First Name Last Name M.I. Sex Male Female Date of Birth S.S.#
B.) Children		First Name Last Name M.I. Sex Male Female Date of Birth S.S.#
C.) Children		First Name Last Name M.I. Sex Male Female Date of Birth S.S.#
D.) Children		First Name Last Name M.I. Sex Male Female Date of Birth S.S.#

Payment Information
Total premium to be charged to Master Card/VISA
Credit Card		VISA MASTERCARD
Account No.
Expiration Date
I want my coverage to start
		Month Day Year

All enrollments received between the 1^st and 15^th of any month will have an effective date of the first. Enrollment forms received between the 16^th and 31^st of the following will be effective the 1^st of the following month.

Upon receipt of the completed on-line enrollment information, an administrative kit consisting of a welcome letter, I.D. card, summary of benefits, and policy will be sent.

Home Page / Important Information / Plan 1 / Plan 2 /
Exclusions & Limitations / Vision Option / Dental Option / How to Apply / Schedule of Premiums / Enrollment Form / Online Enrollment Form / Monthly Automatic Pay Plan Form / RX Information / PPO Information / PPO Networks / FAQ
©2008 SOMA College Health Insurance Plan. All Rights Reserved.

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