Please read the Plan Booklet and Summary of Benefits and Coverage (SBC) prior to enrolling in the Moody Student Health Insurance Plan. The SBC explains in detail the benefits and coverage of each plan offered by Moody and assists in comparing the plans.
Once you have read the plan brochure and SBC thoroughly, please fill out the form below completely to enroll in Moody Bible Institute’s Student Insurance Plan.
To verify that you have read and understood the following, please initial on the line after each statement
I have read the brochure describing this insurance plan.
I realize that I may have out-of-pocket expenses and that there are exclusions (conditions or services for which no benefits are paid) in this plan. I understand that even if I expect the insurance to pay for a service or supplies I will still need to follow the payment policies of the place where the service or supplies are provided, which could mean that payment is due at the time of service.
I understand that Moody Bible Institute’s only provision for meeting students’ medical and health care expenses is through offering the Student Accident and Sickness Insurance Plan and that all medical or health care related expenses that I incur are my own responsibility.
Please Note: Once you are enrolled in the MBI plan, you may not, at any time during the policy year switch between Moody plans; whichever plan you select at the beginning of the year must remain in effect for the entire year.
*Optional Dependent Coverage: If choosing the Student and Spouse, Family, or Student and Child(ren) option, please list dependent(s) below. Please refer to the Student Accident and Sickness Insurance Plan Brochure for premiums.
Dependent #1 Information
Dependent #2 Information
Dependent #3 Information
Dependent #4 Information
Dependent #5 Information