William & Mary sign

Latest about COVID-19 and the Path Forward for fall.

Info for... William & Mary
William & Mary W&M menu close William & Mary

Student Insurance Forms & Documents

2020-2021 Policy

2020 Benefit Summary (PDF)
2020 Continuation Enrollment Form (PDF)
2020 Dependent Enrollment Form (PDF)
2020 Plan Brochure (PDF)
2020 Student Insurance Enrollment Form (online)
2020 Student Insurance Waiver Decision Appeal Form (online)
2020 Student Insurance Waiver Request Form (online)

2019-2020 Policy
2019 Benefit Summary (PDF)
2019 Continuation Enrollment Form (PDF)
2019 Dependent Enrollment Form (PDF)
2019 Plan Brochure (PDF)
2019 Student Insurance Enrollment Form (online)
2019 Student Insurance Waiver Decision Appeal Form (online)
2019 Student Insurance Waiver Request Form (online)
2019 Voluntary Dental Plan Benefit Summary (PDF)
2019 Voluntary Dental Plan Enrollment Form (PDF)
 
General

Claim Information Form (PDF)
Global Travel Plus Assistance Service Brochure (PDF)
Notice of Change of Insurance (PDF)
Payment of Out-of-Network Benefits (PDF)
Pharmacy Claim Form (PDF)
Pharmacy Prescription Drug List (PDF)
UnitedHealth Allies Discount Program Member Handbook (PDF)

Privacy
Authorization from Individual (PDF)
Personal Representative Appointment (PDF)
SHC Release of Info to UHCSR (PDF)