St. John's University
DELTACARE DENTAL PLAN

ENROLLMENT FORM
2018-2019 Policy Year


The 2018-2019 enrollment deadline is August 15, 2018. Your insurance will be effective 09/01/2018 through 08/31/2019. The premium is as follows:

  • Student Only:          $342.00
  • Student + 1:            $551.00
  • Student + Family:    $806.00

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

INTERNATIONAL STUDENTS: If you do not have a social security number, please use your visa number in the "social security number" field below. If your visa number contains a letter, replace each letter with a "9". Additionally, because a social security number is 9-digits long, please use more "9"s at the start of your visa number if it is not long enough to fill the "social security number" field.

 

Asterisk (*) denotes required field

STUDENT INFORMATION

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