SL]FFIELD ACADEMY - Suffield Academy

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Student Health Insurance WaiverÆnrollment
Student's name:
Please choose either option A (Waiver) or B (Enrollment, indicating the appropriate premium) and sign
the form below:
tr A: WAIVER
If you have existing medical insurance coverage:
As parent (guardian),I certify that the student listed above has medical insurance which will cover
expenses incurred by illness or injury while attending Suffield Academy. I have provided a copy of the front and
back of the insurance card (attached it to the Permission for Medical or Surgical Treatment form), which will be
on file in the Suffield Academy Health Center. I decline enrollment in the optional Plan II coverage.
tr B: ENROLLMENT If you do not have existing medical insurance for your child,
you must enroll in Suffield Academy Insurance Plan I.
If you have network-based insurance, you may enroll in Plan II
to supplement your existing coverage.
Please enroll the above named student in the medical insurance program offered through Suffield
Academy. I have enclosed payment in U.S. Dollars for the premium cost of the selected Plan; I understand that
the coverage will begin August 15,2011, or when I pay the premium, whichever date is later.
tr Plan I (Primary Coverage): Premium cost $1f40 (for coverage through August 14,2012)
tr Plan II (Supplemental Coverage): Premium Cost $660 (for coverage through August 14,2012)
tr Plan II: Premium Cost $550 (for coverage only through Jwe 14,2012)
Signature
Date
Please return this form to Suffïeld Academy as soon as possible. Ifwe do not receive the form from you by July 15,2011, we
will automatically enroll you in Plan I and, after that enrollment, we will not be able to arrange a refund from the carrier,
Please do not staple forms
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