Graduate Assistant Health Insurance Enrollment Form

The mailing address you provide on this enrollment form must be the address where you receive your mail. Your insurance card and all other correspondence will be sent to this address. Please ensure the accuracy of the address provided to avoid any delays or issues receiving important information regarding your health insurance.

UAA Student ID Number = 8 characters.

If no middle initial, enter N/A.

Required format: MM/DD/YYYY

The insurance company requires a selection of either M for male or F for female.

(ex. 99508)

Format: (XXX) XXX-XXXX

Enter the semester listed on your contract letter

Please check your type of residency