Student Insurance Forms & Documents

2025-2026 Policy

2025 Continuation Enrollment (through UHCSR My Account)
2025 Dependent Enrollment Form (through UHCSR My Account)
2025 Plan Brochure/Certificate (PDF)
2025 Schedule of Benefits (PDF)
2025 Summary Brochure (PDF)
2025 Student Insurance Opt-In/Enrollment Form (online)
2025 Student Insurance Waiver Request Form (online)

2024-2025 Policy

2024 Continuation Enrollment (through UHCSR MyAccount)
2024 Dependent Enrollment Form (through UHCSR MyAccount)
2024 Plan Brochure/Certificate (PDF)
2024 Schedule of Benefits (PDF)
2024 Summary Brochure (PDF)
2024 Student Insurance Opt-In/Enrollment Form (online)

2024 Student Insurance Waiver Request Form (online)

General

Claim Information Form (PDF)
Global Travel Plus Assistance Service Brochure (PDF)
Notice of Change of Insurance (online)
Payment of Out-of-Network Benefits (PDF)
Pharmacy Claim Form (PDF)
Pharmacy Prescription Drug List (PDF)

Privacy

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