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Insurance Opt In Form
Please answer the questions below to opt in to the CUI Health Insurance Program.
Are You A Full Time or Part Time Student?:
Are You An Undergraduate or Graduate Student?:
What is Your Major?:
Are You A Domestic or International Student?:
I would like to opt in to the Aetna Student Health Plan.
I understand that my student account will be billed for the Spring/Summer premium of $986, which covers January 1, 2014 to July 31, 2014.
I attest that I have read this new federal regulation:
The new HealthCare Reform regulation requires that all potential insured members are notified of the availability of the health insurance plan Summary of Benefits and Coverage (SBC) document. The purpose of the document is to make it easier for you to read and understand the insurance benefits made available to you in a simplified document that is standard across all insurance companies. This will also include pertinent info such as rate information, deductibles, out-of-pocket expenses, limitations and exclusions, etc…You may obtain a copy of your SBC on the student insurance website at:
To Locate the SBC please follow the directions below:
Click on “Find My School’s Plan”
Enter your school name in “School/Association Name”
The SBC will be located under Policy Information
If your student status (full time vs. part time) changes before January 31, 2014, from the time that you submit this form, please advise the Wellness Center so that your bill and insurance coverage can be adjusted accordingly.
Check Box If You Agree To The Terms: