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Association Health Plans (AHPs) - Full Premium Payment

Allegra Association Health Plans, Enrollment Form, Students

  • Applicant Details

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  • Student Information

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  • Plan Selection

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  • Notice To Student

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  • 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.

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  • Billing Details

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