Rust & Associates

college of dupage

International Injury and Illness Insurance

required denotes required fields
BIOGRAPHICAL INFORMATION
First Name: required
Last Name: required
Date of Birth: required (mm/dd/yyyy)
Gender: required
Mailing Address: required Apt
City: required
Country: required
State / Zip Code: required /
Telephone Number: required
Email: required
INSURANCE COVERAGE INFORMATION
College / University Attending: required College of DuPage
Coverage: required Premium Rates Jan 01, 2012 ~ Aug 01, 2012
  Premium Selection   Total Premium
International Participant: = $
Spouse: = $
Each Child: (No. of Children) = $
* Dependent To Be Insured
- Dependent coverage is only available if the participant enrolls in this insurance program.
  First Name/Middle Initial Last Name Gender Date of Birth
Spouse:
Child #1:
Child #2:
Child #3:
APPLICANT NOTICE - By accepting this disclaimer, acknowledgement is made that; 1) you meet the eligibility requirements; 2) if at any time it is determined you did not meet the eligibility requirements for this coverage, the only liability the Company has is the refund of premium, subject to any claims for which benefits has been paid prior to discovery of the ineligibility; 3) the Company assumes no responsibility for notification to the insured prior to or at the termination of coverage for any insured period.
Yes. By accepting this, I certify to the eligibility for insurance of the individuals named hereon.
METHOD OF PAYMENT
Total Amount Charged ($):
Credit Card Type: required
Credit Card Number: required
Expiration Date: required
Billing Option: required Yes, the billing address is same as mailing address
No, I want to use a different address
First Name on the Card: required
Last Name on the Card: required
Billing Address: required
Billing City: required
Billing State / Zip Code: required (required if in U.S.)
Billing Country: required
© 2005-2018 Rust Insurance, Inc. DBA . Rust & Associates . Rust International Associates