UNIVERSITY OF VERMONT
STUDENT HEALTH INSURANCE PLAN
FOR THE 2015-16 ACADEMIC YEAR

DEPENDENT ENROLLMENT FORM


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
student ID: *
first name: *
last name: *
date of birth: * (MM/DD/YYYY)
last 4 digits of social security number: *