Student Health Insurance Enrollment Form - 2019-2020

To begin the enrollment process please enter your demographic information below and click the "next" button at the bottom to continue.

Enrollment is currently open for both the 2018-2019 Policy Year and 2019-2020 Policy Year. For all students incoming or continuing that need to be enrolled from 06/01/2019 - 07/31/2019 your enrollment will be processed for the 2018-2019 Policy Year. Your enrollment will be automatically transferred to the 2019-2020 Policy Year effective 08/01/2019. For students submitting for the 19-20 Policy year effective 08/01/2019 - 07/31/2020 please enter 08/01/2019 as your requested enrollment date. All enrollment dates will be verified for compliance to the DMU Insurance Policy.

Please enter your information. Fields with * are required

Your Student ID is also required. This is the 7 digit number that begins with 0. Continuing students can find this in the My Profile section of My Pulse. Incoming students can find this within your DMU username.

Please add any dependents (Spouse, Domestic Partner, Child):

  • Dependent 1

  • Dependent 2

  • Dependent 3

  • Dependent 4

  • Dependent 5

Add Dependent

Please choose your insurance coverage:

PA Students please enter or select 06/01/2019 for your enrollment date All other students please enter or select 08/01/2019 for your enrollment date. Dependent coverage is not available on the DMU Student Health Insurance Plan.

  • Dependents Also?

If you have any extra documents you would like us to have, please upload them here. Only .doc, .docx and .pdf files are accepted. Up to two documents may be uploaded. Each file may be no larger than 10 Megabytes.

Please Confirm the information you entered, then click submit.

Student Information

Last Name
Middle Initial
1
First Name
Gender
Social Security Number
Student ID
Home Address
Home Address 2
Home City
Home State
Home Country
Home Zip
Phone Number
Personal Email
University Email
Program
Date of Birth

Dependent 1

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 2

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 3

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 4

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Dependent 5

First Name
Last Name
Type
Gender
Date of Birth
Social Security Number

Insurance Information

Medical
Medical For Dependents
Requested Enrollment Date

Documents

Document 1
Document 2

Digital Signature

** By typing your name in the Signature field, you hereby certify that the information entered into this form is true and correct to the best of your knowledge.

  • Comments

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