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.

• First Name *
• Last Name *
• Date Of Birth (mm/dd/yyyy) *
• University or Personal Email Address *

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.

• Last Name *
• Middle Initial
• First Name *
• Gender * - Select - Male Female
• Social Security Number *
• Student ID
• Home Address *
• Home Address 2
• Home City *
• Home State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
• Home Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegowinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic of theCook IslandsCosta RicaCote D'ivoireCroatia (Local Name: Hrvatska)CubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard And McDonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States ofMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint Kitts And NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakia (Slovak Republic)SloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands (British)Virgin Islands (U.S.)Wallis And Futuna IslandsWestern SaharaYemenYugoslaviaZambiaZimbabwe
• Home Zip *
• Phone Number *
• Personal Email
• University Email *
• Class Year/Program 1st Year Medical Student 2nd Year Medical Student 3rd Year Medical Student 4th Year Medical Student 1st Year PA 2nd Year PA 3rd Year PA Other
• Date of Birth (mm/dd/yyyy) *

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

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.

• Please Choose Your Medical Insurance - Select - Medical
  Dependents Also? Yes No
• Requested Enrollment Date (mm/dd/yyyy) *

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.

• Document 1
• Document 2