Student Information

Name of college or university (first select a state, then city, and your school):
Close

Your school is not a current participant in the Student Security Plan. Please contact our office at 847-564-3660 or email us at sales@ejsmith.com to see if your school will be participating soon. You may also want to consider some other insurance options available in your area:
Medical Plans
Short Term Medical Plans

Student's Name:
Billing Address:
Date of birth   
Sex
Social Security Number
Beneficiary

Whom are you enrolling?

Dependent Information

Spouse's or child's name


Sex
Social Security Number
  Date of birth
Child's name


Sex
Social Security Number
  Date of birth
What Benefit Plan Are You Applying For?
Coverage Start Date
  Number of Months Being Paid For
  Premium Due Calculate premium
Is anyone proposed for coverage coverd by Title XIX program (such as, Medicaid)?
If yes, list names of who will be excluded from coverage (separate names with semicolons)
Comments (please include a student account # if you are renewing)
Your enrollment process is almost complete. Simply read the agreement below, and then submit your enrollment form.
By checking this box, I consent to submitting this Enrollment Form and I have reviewed the insurance being offered, exclusions and limitations of the Student Security Group Plan Limited Benefit Hospital Indemnity Insurance. I consent to apply for hospital insurance electronically. This consent applies to the electronic submission, if elected. I can request a paper copy of this form by sending a written request to E.J. Smith & Associates, 899 Skokie Boulevard, Northbrook, IL 60062. I understand that I can withdraw consent by selecting “I Decline”. I verify that I am a registered Student of the above named school and I understand that my eligibility may be subject to verification by the school.
THIS IS NOT MAJOR MEDICAL INSURANCE AND IS NOT A SUBSTITUTE FOR MAJOR MEDICAL INSURANCE. IT DOES NOT QUALIFY AS A MINIMUM ESSENTIAL HEALTH COVERAGE UNDER THE FEDERAL AFFORDABLE CARE ACT.