A student's decision to elect Dental/Vision or not elect Dental/Vision must be retained until the next plan's Open Enrollment period. If the student elects not to enroll in dental/vision coverage, they are not eligible to enroll until the plan's next Open Enrollment period.
* I understand that my dependent(s) cannot be enrolled for a coverage if I am not enrolled for that coverage.
* I understand that the premium amounts shown above are estimations and are for illustrative purposes only.
* Submission of this form does not guarantee coverage. Among other things, coverage is contingent upon underwriting approval and meeting the applicable eligibility requirements as set forth in the applicable benefit booklet.
* If coverage is waived and you later decide to enroll, late entrant penalties may apply. You may also have to provide, at your own expense, proof of each person's insurability. Guardian has the right to reject your request.
* Plan design limitations and exclusions may apply. For complete details of coverage, please refer to your benefit booklet. State limitations may apply.
* Your coverage will not be effective until approved by a Guardian or its designated underwriter.
* I hereby apply for the group benefit(s) that I have chosen above.
* I understand that I must meet eligibility requirements for all coverage that I have chosen above.
* I acknowledge and consent to receiving electronic copies of applicable insurance related documents, in lieu of paper copies, to the extent permitted by applicable law. I may change this election only by providing Guardian thirty (30) day prior written notice.
* I attest that the information provided above is true and correct to the best of my knowledge.
Any person who with intent to defraud any insurance company or other person files an application for insurance or statements of claim containing any materially, false information or conceals for purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and may also be subject to civil penalties, or denial of insurance benefits.