UNIVERSITY OF VERMONT
STUDENT HEALTH INSURANCE PLAN
FOR THE 2016-17 POLICY YEAR

DEPENDENT ENROLLMENT FORM


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)