Graduate Student Health Insurance Enrollment Submission

Graduate Student Health Insurance Enrollment Submission

Please submit your Graduate Student health insurance enrollment through this form.
I have a...*

Engagement AssistantshipResearch AssistantshipTeaching AssistantshipFellowship
Applicable Semester*

Fall 2024Spring 2025Summer 2025Fall 2025Spring 2026
Name of Fellowship
Student Name*

First NameLast Name
UA ID*
Email*
example@example.com
Department*
Student Phone Number*

Area CodePhone Number
Student Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Birthday*

MonthDayYear
Date
Student Biological Sex (Required by Insurance Company)*

MaleFemaleIntersex
Residency*

ResidentNon-resident
Payment Details

This information can be found on your offer information on the second page of your NextGen form.
Exemption Code*
Detail Code*
Upload your award letter
Upload Document:*

Browse Files
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Memo Submission Agreements
I have reviewed the Graduate School Student Health Insurance page found here and understand that I need to enroll in health insurance with UHCSR*

I Agree
I understand that I am fully responsible for any balance due and/or any late fees that are accrued for failure to pay the balance by the fee payment deadline.*

I Agree
Should be Empty:

Payment Details