Summary: Student Health Benefit Plan
2011-2012 Crookston Campus Change, Cancel, Payment,
and Dependent Enrollment 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.
To enroll dependents in the Student Health Benefit Plan, please complete and return this form to The Office of Student Health Benefits before the
Twin Cities campus class registration deadline (listed on the One Stop website). Please keep a copy of this form for your records.
A. Primary Member Information
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) Gender U of M ID Number Social Security Number
Street Address, City, State, Zip Code Daytime Phone Email Address
What would you like to do? Enroll dependent(s): ___ due to birth/adoption ___ due to marriage ___ due to other coverage termination
___ Enroll myself ___ Make a change ___ Cancel coverage for dependent(s) listed ___ Cancel all coverage
B. Enrollment Information--please make plan selection and name all persons to be covered
____ Primary Member, $950/semester ____ One Child, $936/semester
____ Spouse/SSDP*, $1,230/semester ____ Two or More Children, $1,296/semester
_____________ Initial to enroll dependents for both semesters. Option is only applicable fall semester. Contingent on verification by OSHB.