OPTIONAL MAJOR MEDICAL BENEFIT
UNIVERSITY OF NEBRASKA MEDICAL CENTER
2005/2006 STUDENT HEALTH INSURANCE ENROLLMENT FORM
POLICY #AMH9020806

(Please Print)
STUDENT'S NAME______________________________________________________________________________________
                              Last                                              First                                                  Middle

MAILING ADDRESS:                                                 SOCIAL  SECURITY #__________________________

___________________________________________________________________________________________
Street                                                                                                   City                                        State                            Zip

E-MAIL ADDRESS:__________________________

TELEPHONE #:____________________________     DATE OF BIRTH:______________________________

Please check the campus and program in which you are enrolled:

CAMPUS:       ___   Omaha                                       PROGRAM:   ___ Medical Technology
                      ___    Kearney                                                          ___ Medical Nutrition
                      ___    Scottsbluff                                                       ___ Clinical Perfusionist
                                                                                                      ___ 3rd or 4th Year Medical Student
                                                                                                      ___ Other:_________________________

Please check the appropriate coverage period for which you are enrolling:  Reminder: If both semesters are purchased during the Fall Semester, students must continue to be enrolled in the Basic Plan for both semesters for coverage to be valid. (Optional Major Medical Benefit available only if purchased in Fall or Newly Insured for Spring).
COVERAGE PERIOD:         ___  Fall Semester = $110        ___ Spring Semester = $110

I have read the brochure for the effective/expiration dates of coverage for the College/Program for which you are enrolled.  The enrollment dates applicable to your coverage period for the Basic Plan shall also apply to this Optional Major Medical Plan.
Return this enrollment form with your check or money order made payable to National Union Fire Insurance Company:
                                                                  Macori Administration
                                                                  Student Insurance Office
                                                                  P.O. Box 2567
                                                                  Spring, Texas 77383-2567

Rates will not be pro-rated other than as shown above.  This enrollment form must be completed and signed by the student.  It is the student's responsibility to make timely renewal payments on or before the expiration date shown in the brochure.

"I certify that I meet the eligibility requirements for this coverage as described in the brochure.  If it is later determined that I am not eligible,  or that I did not purchase the Basic Plan, my premium will be refunded."

__________________________________                _________________________________
Signature of Student                                                       Date

Underwritten by:
Guarantee Trust Life Insurance Company