Summary: Graduate Assistant Health Plan
2011-2012 Duluth Campus
Department Authorization Form
Please submit to: Office of Student Health Benefits, 410 Church Street S.E., N323, Minneapolis, MN 55455. Fax: (612) 626-5183 or 1-800-624-9881.
Please keep a copy of this form for your records. For more information, visit the Office of Student Health Benefits website at www.shb.umn.edu.
Graduate School Fellows and Trainees are eligible to enroll in the University-sponsored Graduate Assistant Health Plan if their appointing
department has identified an account string (EFS number) to which the cost of the plan may be charged.
The appointing department will incur a charge of $3,897.12 for the entire year OR $324.76 per month. The $324.76 per month breaks down as
follows: $304.00 (plan cost per fellow/trainee), plus $37.92 (surcharge for department's portion of the University subsidy of dependent coverage),
minus $16.16 (fellow/trainee's contribution to premium). Post Doctoral Fellows must submit payment for their portion of the cost of coverage
($96.96 per semester or $193.92 per year).
Demonstration of fellow and trainee eligibility for the Graduate Assistant Health Plan requires a) completion of a Department Authorization Form
and b) completion of an Enrollment Form. To complete the enrollment process, the fellow or trainee must submit these two documents to the
Office of Student Health Benefits by September 19, 2011 or within 14 days of their appointment start date, whichever is later. Coverage for those
who miss the deadline will begin on the date this form is processed by the Office of Student Health Benefits. Please keep a copy of this form for
A. Fellow or Trainee Information
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) Gender U of M ID Number