Summary: AHC Student Health Benefit Plan
2011-2012 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 AHC 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 ____ Cancel coverage for dependent(s) listed ____ Cancel all coverage
____ Make a change (Name and address changes must be in One Stop before it can be changed in OSHB records.
Go to www.onestop.umn.edu > Quick Links > Student Records > Personal Information)
B. Enrollment Information--please make plan selection and name all persons to be covered
___ Primary Member, $1,340.00/semester ___ One Child, $1,326.00/semester