North Park University

AIP Customer Service

Your Customer Service Team at Associated Insurance Plans International, Inc can be reached at 800-452-5772. Our telephones are staffed Monday through Friday, 8:00AM to 7:00PM Central Standard Time. Email us at office@aipstudentinsurance.com.

Customer Service Representative
Joni Matthews, extension 1225

Customer Service Representative
Vicki Baran, extension 1207

For School Administrators Only

Online Enrollment Card

Please be sure to provide as much accurate information as possible. Providing false information is considered deceitful. The information you have provided will be verified and submitted to your College or University.

Personal Information

*All fields required

First Name:

Last Name:

M/F:

Address:

City:

State:

Zip:

Phone:
--

E-mail:

North Park University 7-digit Student ID #:

Date of Birth (mm/dd/yyyy):

I wish to enroll in the Student Health Insurance Plan.
Yes No, I would like to waive this coverage. (Note: Please complete the Online Waiver Form.)

I wish to purchase coverage for:
Student Only
Student & Spouse
Student, Spouse & Children
Student & Children

I wish to enroll for the following term:
Annual

Dental,
Vision &
Pharmacy
Options

Individual
Insurance
Options

If you wish to see alternatives to our student insurance programs, please consider our Individual Insurance Plans.

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Name:	Date of Birth (mm/dd/yyyy):
Name:	Date of Birth (mm/dd/yyyy):
Name:	Date of Birth (mm/dd/yyyy):
Name:	Date of Birth (mm/dd/yyyy):
Name:	Date of Birth (mm/dd/yyyy):