PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

An asterisk * denotes a required field.

First Name: *
Middle Initial:
Last Name: *
Student ID:
Email Address: *
Local Address: *
Local Address (cont.):
Local City: *
Local State: *
Local Zip Code: *
Date of Birth: *  (MM/DD/YYYY)
Gender: *
 

Detailed information about the plan, including co-pays, deductibles and provider network can also be found on the left hand side of this page.

 

Student Health Plan

Optional Plans

Additional Information

University Health Plans Broker License # 000123936000
William E. Devine Broker License # 34773