Summary: Graduate Assistant Health Plan
2011-2012 Duluth Campus
Change or Cancellation 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 make changes to your account information, please complete relevant portions of this form and return to the Office of Student Health Benefits.
Please keep a copy of this form for your records.
A. Graduate Assistant 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
For name or address changes, before submitting this form please update your address at www.onestop.umn.edu. Go to Quick Links < Student
Records < Personal information. University records must be updated before our office can process name or address changes.
___ My contact information has changed. My new contact information is entered above.
___ My name changed. My new name is entered above. Before the change, my name was: ___________________________________________
B. Dependent Additions--choose plan and name dependents to be added (all must be on same plan)
Plan 1 Member Payment** Plan 2 Member Payment**