Citrus College - International Student Insurance Enrollment Form

Personal Details - Please make sure to enter information carefully! Please DON'T use all CAPITALs!

Enter the name you registered with at Citrus College
 +
Gender *
Marital Status *
Citizenship/Passport Country is the same as Nationality/Birth Country
NOTE: Please provide us with your Citrus College email address. Your insurance policy and
card will be sent to this email.
 
(PLEASE USE ALL LOWER-CASE)
Residence  Address
Address in U.S. to receive important information

Dependent Details

Spouse Coverage Required? *
Children Coverage Required? *

Spouse Details

Spouse must not be a full-time student to add them to plan *
As your spouse is a full-time student, the spouse is required to obtain a separate individual quote.
Gender *
 +

Children Details

Child 1:
Gender *
 +

Child 2:
Gender *
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Coverage Details

Applicant School Term *
Spouse School Term *
Child School Term (1 Child) *
Child School Term (2 Children) *

Application for this plan of benefits may require that you provide us with sensitive personal information about you and your enrolling dependents. In accordance with the privacy policy posted on our website, we will require your consent and the consent of those dependents you are applying for to process this application.

In the event that your application is approved we will require your continuing consent to administer your plan and this will include pre-authorization of medical services, claims administration and appeals.

Our privacy policy provides information concerning the use and disclosure of your personal information including your rights under this policy. This privacy policy is in compliance with GBG’s data protection policies and those of the European Union (EU) General Data Protection Regulation (GDPR). Throughout the year the terms of the privacy policy may be updated. You can find the most recent version at our website http://gbg.com/#/AboutGBG/PrivacyPolicy.

Your personal information, including special category or sensitive personal information such as medical and health details which you supply to the insurer may be used in many ways including, but not limited to: processing and underwriting your application for insurance, deciding whether an offer of insurance coverage can be made and on what terms, administering your policy and handling claims, and detecting and preventing fraudulent activity. Other GBG affiliates and third parties who provide services to the insurer could use your information in the same manner and further detail in respect of the transfer of your data to third parties is contained in the privacy policy.

By ticking the box “I CONSENT”, you consent to the use and disclosure of your healthcare information in accordance with our privacy policy. If you do not consent to the use and disclosure of your healthcare information GBG will not be able to evaluate your request and therefore will not be able to provide you with insurance cover. The following application should only be completed if you are willing to provide consent.

Applicant Signature (Please click inside the signature box to sign) *
clear
 *

NOTE Very Important:  Please click on submit below and make sure you get a confirmation.  If you do not get confirmation email please send us an email to citrusgbg@accessedusa.org.  Thank You!

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