By checking this box, you give consent for us to process your data and agree to the following: I hereby authorize WellAway Limited and its third party administrator, PayerFusion Holdings, LLC, to make disclosure of all of my protected health information related to the provision of and payment for my health care benefits or services to: Global Secutive LLC, 116 Village Blvd, Suite 306, Princeton, NJ 08540. This authorization will expire one year from the date on which it was signed. I understand that I have the right to revoke this authorization at any time, and that if I revoke this authorization, I must send a written request to the third-party administrator: PayerFusion Holdings, LLC, 2100 Ponce de Leon Boulevard, Mezzanine - Suite 200, Coral Gables, FL 33134, attention Claims Department. I understand that this authorization is voluntary. I understand that I may refuse to sign this authorization and that my refusal will not affect my ability to obtain treatment, payment of claims, enrollment, or eligibility for benefits.

I understand that in order to be eligible for this policy, I must be a full-time student (other than during a college/university scheduled winter, spring or summer eak) enrolled in either: (a) an accredited educational program or in an associate, bachelor, master, or Ph.D. program at a university or other recognized higher education institution; (b) a language-training program; or (c) a vocational program. Students must actively attend classes. Home study, correspondence, and online courses do not fulfill the eligibility requirements that the student actively attend class. I understand that Hybrid status is allowed, but I must follow my academic institution's rule on Hybrid status. I understand that WellAway has the right to investigate eligibility status and attendance records to verify eligibility requirements are met. If it is discovered the eligibility requirements are not met, the insurance coverage will be terminated.

I understand that in order to be eligible for this policy, I must be in good health (not currently undergoing medical Treatment or Services or where distinct signs or Symptoms are evident as of the Policy Effective Date), not hospitalized and not confined to a Hospital or Extended Care Facility.

I understand that in order to be eligible for this policy, in the event I had previous coverage with WellAway under a different policy, I am only eligible for this Policy if this Policy provides the same level or less coverage then I previously had with WellAway.

I understand that in order to be eligible for this policy, the minimum Policy Period must be the entire duration I actively attend classes and for the duration required by my educational institution I am attending (each semester or annually).

I understand that with respect to my dependents,

1. As of the Policy Effective Date, Dependent(s) must be in good health (not currently undergoing medical Treatment or Services or where distinct signs or Symptoms are evident as of the Policy Effective Date), not hospitalized and not confined to a Hospital or Extended Care Facility.
2. In no event will a Dependent be eligible if the Policyholder is not eligible and the Policy Period will be the same as the Policyholder.
3. WellAway has the right to investigate eligibility status. If it is discovered the eligibility requirements are not met, the insurance coverage will be terminated.

I understand that in order to be eligible for this policy, I may not be pregnant at the time of enrollment and pregnancy must occur after the Policy Effective Date unless I maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy. No coverage will be provided for any Treatment or Services related to pregnancy, or any Complications of Pregnancy, including delivery if I am pregnant prior to the Effective Date unless I maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy.

By checking this box, you give consent for us to process your data and agree to the following:

• I understand that with respect to my dependents, my Dependent spouse (if applicable), may not be pregnant at the time of enrollment and pregnancy must occur after the first ten (10) months of the Policy Effective Date unless the Dependent spouse maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy. No coverage will be provided for the Dependent spouse for any Treatment or Services related to pregnancy, or any Complications of Pregnancy, including delivery which arise during the first ten (10) months of this Policy Period unless the Dependent spouse maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy.
• I understand that with respect to my dependents, Dependent(s) must be in good health (not currently undergoing medical Treatment or Services or where distinct signs or Symptoms are evident as of the Policy Effective Date), not hospitalized and not confined to a Hospital or Extended Care Facility.
• I understand that with respect to my dependents, In no event will a Dependent be eligible if the Policyholder is not eligible, and the Policy Period will be the same as the Policyholder. WellAway has the right to investigate eligibility status. If it is discovered the eligibility requirements are not met, the insurance coverage will be terminated.

I understand that in order to be eligible for this policy, the policy must be effective within 30 days of the start date of my academic program and must remain in effect for the entire duration of my academic year.

I understand that with respect to my dependents, in order for them to be eligible, they must be in good health (not currently undergoing medical Treatment or Services or where distinct signs or Symptoms are evident as of the Policy Effective Date), not be pregnant, not hospitalized and not confined to a Hospital or Extended Care Facility.

I understand that in order to be eligible for this policy, I must be a full-time student (other than during a college/university scheduled winter, spring or summer eak) enrolled in an accredited educational program or in an associate, bachelor, master, or Ph.D. program at a university or other recognized higher education institution. I must actively attend classes. Home study, correspondence, and online courses do not fulfill the eligibility requirements that I actively attend class. I understand that Hybrid status is allowed, but I must follow my academic institution's rule on Hybrid status. I understand that WellAway has the right to investigate eligibility status and attendance records to verify eligibility requirements are met. If it is discovered the eligibility requirements are not met, the insurance coverage will be terminated.

I understand that with respect to my dependents, my spouse may not be pregnant at the time of enrollment and pregnancy must occur after the first ten (10) months of the Policy Effective Date unless my Dependent spouse maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy. No coverage will be provided for my Dependent spouse for any Treatment or Services related to pregnancy, or any Complications of Pregnancy, including delivery which arise during the first ten (10) months of the Policy Period unless my Dependent spouse maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy.

I understand that in order to be eligible for this policy, I may not be pregnant at the time of enrollment and pregnancy must occur after the Policy Effective Date unless I maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy. No coverage will be provided for any Treatment or Services related to pregnancy, or any Complications of Pregnancy, including delivery if I am pregnant prior to the Effective Date unless I maintained the same coverage under the same plan with WellAway within at least 63 days prior to the Effective Date of this Policy.

By checking this box, you give consent for us to process your data and agree to the following:

1. You consent to the use and disclosure of your personally identifiable information, including sensitive health information, and other information in accordance with our Privacy Policy. If you do not consent to the disclosure of your personal information, we will not be able to evaluate your request and will not be able to provide you with the medical program, including the insurance product offered by Crum & Forster, SPC. For information regarding the use and disclosure of your personal information, please visit https://www.studenthealthusa.com/privacy-policy.html.
2. By purchasing this coverage, you agree to subscribe and become a participant in the Fairmont Specialty Trust and understand that participation in the Trust is a prerequisite to procuring the insurance coverage. Click for a copy of the subscription agreement.
3. This insurance coverage is not subject to and does not provide certain insurance benefits required by the United States’ Patient Protection and Affordable Care Act (“PPACA”). PPACA requires certain US citizens or US residents to obtain PPACA compliant health insurance, or “minimum essential coverage.” In some cases, certain individuals may be deemed to have minimum essential coverage under PPACA even if their insurance coverage does not provide all of the benefits required by PPACA. Please consult an attorney or tax professional to determine whether this insurance coverage meets any obligations you may have under PPACA.
4. This plan contains both insurance and non-insurance benefits. Insurance benefits are provided by Crum & Forster SPC through ITI SP pursuant to a policy issued to the Fairmont Specialty Trust.

I understand that I will not be able to use the virtual care services until up to 72 hours after my enrollment in the program.