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Student Insurance Forms & Documents

2020-2021 Policy

2020 Continuation Enrollment Form (through MyAccount)
2020 Dependent Enrollment Form (through MyAccount)
2020 Plan Brochure/Certificate (PDF)
2020 Schedule of Benefits (PDF)
2020 Summary Brochure (PDF)
2020 Summary of Benefits & Coverage (PDF)
2020 Student Insurance Enrollment/Opt-In Form (online) Now Closed!
2020 Student Insurance Waiver Request Form (online) Now Closed!
2020 Student Insurance Waiver Decision Appeal Form (online) Now Closed!

2021-2022 Policy

2021 Continuation Enrollment Form (through MyAccount) - Enrollment not available at this time
2021 Dependent Enrollment Form (through MyAccount) - Enrollment not available at this time
2021 Plan Brochure/Certificate (PDF)
2021 Schedule of Benefits (PDF)
2021 Summary Brochure (PDF) 
2021 Summary of Benefits & Coverage (PDF)
2021 Student Insurance Enrollment/Opt-in Form (online) - Expected to open on or around 07/01
2021 Student Insurance Waiver Request Form (online) - Expected to open on or around 07/01

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)
UnitedHealth Allies Discount Program Member Handbook (PDF)

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