Student Hospitalization Insurance

This form is designed to be filled out in your Web browser, printed, then submitted either in person, by mail or by fax. It cannot be submitted online.

Please fill in the following fields.
University ID number
Name (last, first, middle, former)
Term Fall
Spring
May Session
Summer
Year
If you are taking 6 or more credits (3 or more credits in summer) and are a degree-seeking student, you are required to have hospitalization insurance. The University-sponsored hospitalization insurance will automatically be charged to your student account unless you check the box below, fill in the name of your insurance company and policy number, and sign the bottom of this form. If you do not provide complete information, you will be charged for insurance. You may receive a full refund by returning this information to one of the student service centers or by accessing your student record through the Web by the end of the first week of classes. This information
is subject to periodic audits. Providing inaccurate or false information may result in unexpected charges. It is also a violation of the Student Conduct Code. (NOTE: Do not complete this form if your are registered for fewer than 6 credits [fewer than 3 credits in summer], or are not enrolled in a degree program.)

Please check one of the options below:

I am adequately covered by the hospitalization insurance listed below.

Name of company
Telephone number
Member ID number

I have applied for and am enrolled in the Graduate Assistant Health-Care Plan.

Please fill in the following fields.

Student signature

 

  
Date

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Registration Questions:
Phone: 612-624-1111
One Stop Web Site
Web Registration

In-Person Registration:
One Stop Student Service Centers:
200 Fraser Hall (East Bank)
130 Coffey Hall (St Paul)
130 West Bank Skyway (West Bank)

Mail and Fax Registration:
University of Minnesota
200 Fraser Hall
106 Pleasant Street SE
Minneapolis, MN 55455
Fax: 612-626-0008