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.

Please enter your information. Fields with * are required

HELPFUL TIPS:
* Student ID is not a required field.
* If you don't know your University Email address, you may enter your personal email address instead.

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:

HELPFUL TIPS:
*For incoming students and continuing students enrolling during the Open Enrollment period (8/1/2017 - 8/31/2017), the requested effective date will be 08/01/2017.
*For continuing students enrolling outside of an Open Enrollment period, as a result of an involuntary loss of other coverage, the requested effective date will be the date you lost other coverage.

  • 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

This form is SSL secured.