HTH - Group Enrollment Acceptance Agreement

Northwestern University

This plan is designed for and open to faculty and staff employed by Northwestern University.

I hereby certify that as a proposed participant, I am employed by Northwestern University and will be a Northwestern University employee for the entire duration of my international travel. I further certify that I am not a citizen of my destination country or countries and that my travel to destination country or countries is for Northwestern University business purposes. Further, I understand that a participant whose coverage under this policy lapses shall be subject to all policy exclusions as of any subsequent effective date and I understand that the Company will pay benefits for Pre-Existing Conditions.

Verification of visa and employment may be required at the time of claim submission.