This enrollment form is for the TOTAL CHOICE PLAN. If you meant to enroll in the DeltaCare Dental Plan, please click "Enrollment Form" on the left of this page under the DeltaCare section.
If you purchase the plan now, your coverage will be effective November 1, 2023 through October 31, 2024. The enrollment deadline is midnight on October 10, 2023.
TO CONTINUE THE ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:
If you have a social security number you are required to enter it below. If you are an international student and do not have a social security, please use your student ID and add leading zeros if necessary to make it a 9-digit number.