Home

About

Advanced Search

Browse by Discipline

Scientific Societies

E-print Alerts

Add E-prints

E-print Network
FAQHELPSITE MAPCONTACT US


  Advanced Search  

 
Graduate Assistant Health Plan 2011-2012 Declaration of Domestic Partnership
 

Summary: Graduate Assistant Health Plan
2011-2012 Declaration of Domestic Partnership
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 a domestic partner as a dependent on a University-sponsored, Office of Student Health Benefits administered health plan, complete this
form and submit to the Office of Student Health Benefits. 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
_____________________________________________________
B. Domestic Partner Information
_______________________________________________________________________________________________________________________
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) Gender Social Security Number
_____________________________________________________
C. Domestic Partner's Child(ren)
_______________________________________________________________________________________________________________________
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) Gender Social Security Number

  

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

 

Collections: Power Transmission, Distribution and Plants