NOTICE TO STUDENT: Coverage will be effective the date thecorrect premium is received by the companyor a representative of the Company or the effectivedate of the coverage period,whichever is later,unless otherwise statedin the Schedule of Benefits. B y signing the studentacknowledges the following: 1) He/She has carefully read the Summary of Benefits and elects to enroll as indicated on this enrollment card; 2) He/Shemeets the eligibility requirements for this coverageas described in the brochure; 3) Upon enrollment we require the 1st and last month's premium; and 4) Acknowledge this plan does not provide comprehensive major medical services. Cancellations must be submitted at least 5 days prior to the recurring ACH billing date. PREMIUM WILL NOT BE REFUNDED EXCEPT FOR INELIGIBILITY OR ENTRANCE INTO THE ARMED FORCES