Summary: Voluntary Student Dental Plan
2011-2012 Enrollment, Change, and Cancel 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 request enrollment, make a change, or cancel your enrollment request, please complete and return this form to The Office of Student Health
Benefits by September 19, 2011. Please keep a copy of this form for your records.
A. 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
Please select your campus ____ Twin Cities ____ Crookston ____ Duluth ____ Morris
What would you like to do? ____ Request enrollment in the Voluntary Student Dental Plan
____ Cancel Voluntary Student Dental Plan enrollment request
____ Make a change--Please note, name and address changes must be made through your campus registration
website before changes can be made in OSHB records. Follow directions below for your campus:
Twin Cities Campus students: Go to www.onestop.umn.edu > Quick Links > Student Records > Personal Info
Duluth Campus Students: Go to www.d.umn.edu/students > Technology > Update Personal Information
Crookston Campus Students: Go to www3.crk.umn.edu/onestop > Registration > Update Personal Information