UNIVERSITY OF VERMONT
STUDENT HEALTH INSURANCE PLAN

2018-19 DEPENDENT ENROLLMENT FORM FOR SPRING STUDENTS ONLY


TO CONTINUE THE DEPENDENT ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
social security number:
student ID: *
date of birth: * (MM/DD/YYYY)