Association Health Plans (AHPs) - Full Premium Payment Allegra Association Health Plans, Enrollment Form, Students Applicant Details*This information is requiredStudent Name* First Middle Last Home Country* Visa Type F1 J1 M1 Date of Birth* Gender* Male Female Email* Phone*Broker/Agent*Please Choose OneNoneAkel, PeterAltamirano, ArmandoBelbel, IsaacCisneros, EnriqueCooper, JorgeDorman, KevinDorman, WesFigueroa, RoxanneFlores, LindaHernandez, FernandoHUB, InternartionalMacias, JuanMartinez, VianeyMcCormick, DonMiramontes, ValeriaMitchell, JohnMurphy, AbbyMurphy, ToddOrtiz, GustavoPoynter, JasonRhodes, NormanRomero, JohnSeaman, PhilSeanez, ElenaTrevino, FranciscoTrevino Jr., JorgeTrevino, MarthaVarela, MikeVelasco, MarthaStudent Information*This information is requiredStudent ID* Campus Location* Expected Graduation Date* Plan Selection*This information is required$25 Association Enrollment Application and Administration Fee* Price: PlansBasic Plan (Select all that apply) Basic Premium Plan Plus Plan (Select all that apply) Plus Premium Plan Notice To Student*This information is requiredTerms*NOTICE TO STUDENT: Coverage will be effective the date the correct premium is received by the company or a representative of the Company or the effective date of the coverage period, whichever is later, unless otherwise stated in the Master Policy. B y signing the student acknowledges the following: 1) He/She has carefully read the brochure and elects to enroll as indicated on this enrollment card; 2) Rates are not pro=rated other than as listed on this enrollment card; 3) He/She meets the eligibility requirements for this coverage as described in the brochure; and 4) If it is later determined that the student is not eligible, the premium will be refunded. 5) Acknowledge this plan does not provide comprehensive major medical services. PREMIUM WILL NOT BE REFUNDED EXCEPT FOR INELIGIBILITY OR ENTRANCE INTO THE ARMED FORCES. I UNDERSTAND THAT I MUST BE A COLLEGE STUDENT/SCHOLAR AT COLLEGE TO PURCHASE THIS HEALTH COVERAGE Signature or Initials* Name* First Middle Last Date* MM slash DD slash YYYY Billing Details*This information is requiredSecure Credit Card Card Holder* Card Number* Card Expiration* Card CVV* Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code You authorize regularly scheduled monthly charges to your checking/credit card account. A receipt for each transaction will be automatically emailed to you with the contracted fee amount you have agreed too.* I ConsentTotal $0.00 CAPTCHA
