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General Information : Important Forms

Documents

Adobe Acrobat PDF
Insurance Late Withdraw / Enroll Appeal Form (37.5 K)
Insurance Late Withdraw / Enroll Appeal Form
Microsoft Word
Insurance Late Withdraw / Enroll Appeal (39.5 K)
Insurance Late Withdraw / Enroll Appeal
Adobe Acrobat PDF
International Student Health Insurance Waiver - 2008-2009 (60.1 K)
International Student Health Insurance Waiver - 2008-2009
Adobe Acrobat PDF
International Student Health Insurance Waiver - 2009-2010 (60.2 K)
International Student Health Insurance Waiver - 2009-2010
Adobe Acrobat PDF
Coverage Status Change Form (33.7 K)
Coverage Status Change Form
Adobe Acrobat PDF
Dependent Information Form (23 K)
Dependent Information Form
Adobe Acrobat PDF
Pharmacy Access Enrollment Form for Covered Dependents (16.2 K)
Pharmacy Access Enrollment Form for Covered Dependents
Adobe Acrobat PDF
Student Health Insurance Claim Form (72.9 K)
Student Health Insurance Claim Form
Adobe Acrobat PDF
Affidavit of Domestic Partnership (35.9 K)
Affidavit of Domestic Partnership
Adobe Acrobat PDF
Termination of Domestic Partnership (25.5 K)
Termination of Domestic Partnership
Adobe Acrobat PDF
Interim Insurance Request Form for International Students - AU09 (19.3 K)
Interim Insurance Request Form for International Students - AU09
Adobe Acrobat PDF
Interim Insurance Request Form for Domestic Students - AU09 (19.3 K)
Interim Insurance Request Form for Domestic Students - AU09
Adobe Acrobat PDF
Military Status Form - 2009-2010 (18.9 K)
Military Status Form - 2009-2010

To the right, please find all of the Important Forms to manage your enrollment status in the Student Health Insurance Plan.

  • The Insurance Late Withdraw/Enroll Appeal Form can be used if you have missed a deadline for adding or dropping your insurance.  Please understand that deadlines are strictly enforced. 

 

  • International Students must use the International Student Waiver form to waive out of the Comprehensive Plan

 

  • The Coverage Status Change form is used if you need to change your level of coverage in the middle of the year due to a Qualifying Event. 

 

  • The Dependent Information Form is used to provide dependent information to the insurance company after you have enrolled your dependents in the plan. 

 

  • The Pharmacy Access Enrollment Form for Covered Dependents allows your covered dependents to use the pharmacy at the Wilce Student Health Center.  By going to Wilce, they will only have to pay the co-insurance on covered prescriptions.

 

  • The Insurance Claim Form can be used to file claims with Klais and Company.

 

  • The Affidavit of Domestic Partnership form is required to cover your same-sex or opposite-sex partner on the Student Health Insurance Plan.  Please see the form for eligibility requirements.

 

  • The Termination of Domestic Partnership form may be used to terminate your domestic partner from your insurance.  Note: Your partner will remain on the plan until the end of the term. 

 

  • The Interim Insurance Request Form can be used for eligible international or graduate students enrolling at the University for the first time to request an additional month of coverage at the beginning of Autumn quarter.

 

  • For students who are called up to Active Duty in the armed forces in the middle of a quarter, use the Military Status form to drop the insurance plan.