Middlebury College

Voluntary Insurance Enrollment Form

Summer 2012
Summer faculty and staff members who are not J1 Exchange Visitors may elect to purchase the
Accident and Sickness Insurance Plan for the summer at the cost of $107.00 per person. If you
wish to take advantage of the opportunity, please provide the necessary information below.
Name______________________________________ College ID#________________________
Last

First

Date of Birth_________
MM/DD/YY

MI

Male____ Female_____ Telephone No.______________________

(Please check)

US Mailing Address_____________________________________________________________
Street
___________________________________________________________________________________________
City
State
Zip Code

Dependent Enrollment
If enrolling dependents, please list below. Dependent coverage is available only if the Employee is
enrolled in the Middlebury College Summer Accident and Sickness Insurance Plan. Dependent coverage
expires concurrently with that of the Insured.
Name

Gender

Spouse__________________________________________________
Last

First
First
First

________

___

________

___

________

MI

Child __________________________________________________
Last

___

MI

Child __________________________________________________
Last

Date of Birth

MI

RATES/ELIGIBILITY
All Summer Language School Employees holding J-1 visas and their eligible dependents on J-2 visas
will be automatically enrolled into the Summer 2012 Exchange Visitor Accident and Sickness
Insurance Plan. All other Summer Language School Employees and Lecturers are eligible for
coverage and can enroll on a voluntary basis.
$107.00 per person will be automatically deducted from your paycheck in equal installments. Please note
that once Middlebury College makes payment to the insurance company no refunds or prorate of
premium will be made if you or your dependents are no longer in need of the insurance. Please notify us
by May 15, 2012 of any changes.
By signing below, I acknowledge the following: 1) I have read the brochure and elect to enroll as indicated. 2)
Rates are not pro-rated. 3) I permit Middlebury College to provide Gallagher Koster with my eligibility status for
purpose of eligibility under this plan. 4) I warrant that the information I have provided on this application form is
true and I am aware that if I provide false information, my coverage, and coverage for my spouse and child(ren) may
be made void. 5) I understand that if it is later determined that I am not eligible, the premium will be refunded, and
any claims paid will be solely my responsibility but the premium is not refundable for reasons other than eligibility.
Signature_________________________________________________________ Date______________________
Last updated 1/12