Summary: Graduate Assistant Health Plan
2011-2012 Twin Cities Campus
Continuation of Coverage 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.
After losing eligibility for the Graduate Assistant Health Plan (for example, your assistantship drops below 25%, you leave your appointment, or
your appointment, fellowship, or traineeship ends), plan members have the option to continue coverage for up to 18 months at their own expense.
To request continuation, please complete and return this form to the Office of Student Health Benefits within 60 days of loss of coverage. For more
information on this option, contact 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 continue my coverage--$351.39
___ Yes, I wish to continue my dependent coverage--choose plan below
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**