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StudentHealthBenefitPlan 20102011TwinCitiesCampusChange,Cancel,Payment,
 

Summary: StudentHealthBenefitPlan
20102011TwinCitiesCampusChange,Cancel,Payment,
andDependentEnrollmentForm
Pleasesubmitto:OfficeofStudentHealthBenefits,410ChurchStreetS.E.,N323,Minneapolis,MN55455.Fax:(612)6265183or18006249881.
Pleasekeepacopyofthisformforyourrecords.Formoreinformation,visittheOfficeofStudentHealthBenefitswebsiteatwww.shb.umn.edu.

ToenrolldependentsintheStudentHealthBenefitPlan,pleasecompleteandreturnthisformtoTheOfficeofStudentHealthBenefitsbeforethe
TwinCitiescampusclassregistrationdeadline(listedontheOneStopwebsite).Pleasekeepacopyofthisformforyourrecords.
_____________________________________________________
A.PrimaryMemberInformation

______________________________________________________________________________________________________________________
Name(Last,First,MiddleInitial)(PleasePrint)DateofBirth(mm/dd/yyyy)GenderUofMIDNumberSocialSecurityNumber

______________________________________________________________________________________________________________________
StreetAddress,City,State,ZipCode DaytimePhone EmailAddress

Whatwouldyouliketodo? Enrolldependent(s):____duetobirth/adoption____duetomarriage____duetoothercoveragetermination

____Enrollmyself____Cancelcoveragefordependent(s)listed____Cancelallcoverage

  

Source: Amin, S. Massoud - Department of Electrical and Computer Engineering, University of Minnesota

 

Collections: Power Transmission, Distribution and Plants