Graduate Student Health Insurance
UnitedHealthcare Student Resources

Enrollment for Students and Dependents

Health Insurance coverage will be effective the date the correct premium is received by the Company, a representative of the Company, or the effective date of the coverage period. The enrolling student acknowledges the following:

1) He/She has carefully read the brochure and this enrollment form;

2) Health Insurance Premiums will not be refunded except for ineligibility or entrance into the armed forces.

AU Banner ID#

Primary Insured Last Name

Primary Insured First Name

Date of Birth (MM/DD/YYYY)

mm/dd/yyyy

Gender

Mailing Address

Apt #

City

State

Zip Code

AU Email

Phone #

Your AU profile

Do you have an assistantship?

Dependent(s) Information

Please enter any dependents you need to enroll for insurance.

Spouse Last Name

Spouse First Name

Spouse Date Of Birth (MM/DD/YYYY)

mm/dd/yyyy

Relationship and Gender

Female

Male

Child Last Name

Child First Name

Child Date of Birth (MM/DD/YYYY

mm/dd/yyyy

Child Gender

Female

Male

Child 2 Last Name

Child 2 First Name

Child 2 Date of Birth (MM/DD/YYYY

mm/dd/yyyy

Child 2 Gender

Female

Male

Child 3 Last Name

Child 3 First Name

Child 3 Date of Birth (MM/DD/YYYY

mm/dd/yyyy

Child 3 Gender

Female

Male

Enrollment for 2022-2023

I hereby elect to enroll in the AU Graduate Student Group Health Insurance Program and understand the following applicable rules:

1 This program is available only to AU enrolled graduate students or international students – see eligibility criteria.

2 International students who are on OPT are also allowed to enroll in this insurance.

3 All non-assistantship graduate students taking a minimum of 6 credit hours are eligible to enroll in this insurance plan on a voluntary basis. On-line credits count toward the minimum hours, but may not exceed 50% of hours required for eligibility.

4 I will be responsible for full payment of all premiums as charged to my bursar bill, failure to pay said premiums will result in cancellation of my schedule and collections procedures being implemented.

5 Students must actively attend classes for at least the first 31 days after the date for which coverage is purchased.

Please only check ONE option

Alternate Enrollment Option

Please note we only enroll per semester. No annual enrollment. You must request enrollment by semester. MONTHLY START OPTION IS ONLY FOR STUDENTS THAT AGE OUT OF CURRENT COVERAGE UNDER THEIR PARENTS INSURANCE OR SPOUSE'S COVERAGE OR HAS ANOTHER SITUTATION WHERE CURRENT INSURANCE HAS ENDED. CHOOSE THE MONTH YOU NEED COVERAGE TO BEGIN FOR START DATE.THE END DATE WILL AUTOMATICALLY BE THE END OF THE CURRENT POLICY TERM. FOR EXAMPLE: FALL ENROLLMENT REQUEST AFTER POLICY HAS BEGUN: 7/22/2022 WILL RUN THROUGH 2/15/2023. SPRING 3/21/2023 WILL RUN THROUGH 8/15/2023. ALL TERMS ARE LISTED IN THE DROPDOWN BOX ABOVE. THANK YOU!

Did you lose/age out of insurance coverage?

IF YOU ANSWER YES, PLEASE SELECT A START DATE BELOW.

Start Date

mm/dd/yyyy

Students Electronic Signature (Please Type Name)

Form Date Field

mm/dd/yyyy

Send me a copy of my responses

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Graduate Student Health InsuranceUnitedHealthcare Student Resources

Dependent(s) Information

Enrollment for 2022-2023

Alternate Enrollment Option

Graduate Student Health Insurance
UnitedHealthcare Student Resources