Summary: Graduate Assistant Health Plan
2011-2012 Twin Cities Campus
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 in the Graduate Assistant Health Plan, please complete and return this form to The Office of Student Health Benefits by September 19,
2011 or within 14 days of your 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 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
___ Yes, I wish to enroll in the Graduate Assistant Health Plan--I understand my portion of the cost of the plan will be calculated according to my
appointment type. (Please see back of this form for details.)
B. Dependent Enrollment Information--choose plan and name dependents to be covered (all must be on same plan)
Plan 1 Member Payment** Plan 2 Member Payment**
___ Spouse/SSDP* $275.83/month ___ Spouse/SSDP* $190.95/month