WWAMI United Healthcare Enrollment Form

If you see this don't fill out this input box.

WWAMI students are invited to enroll in the UAA Graduate Student Healthcare Benefits Plan.

UAA Student ID Numberrequired

Provide UAA Student ID Number. (Do not use your UW ID Number.)

Last Namerequired

First Namerequired

Middle Initial required

If you do not have a middle name, please enter N/A

Date of Birthrequired

MM/DD/YYYY

Genderrequired

This insurance requires a selection of M for male or F for female.

Current Street Addressrequired

Current Street Address (continued)

Choose: Apt #, Building #, Suite #, Space #, etc.

Cityrequired

Staterequired

Zip Coderequired

Preferred Email Addressrequired

Telephone Numberrequired

Format: (XXX) XXX-XXXX

Coverage periods are only available under the current academic year's policy.

Date Monthly Coverage Begins

If monthly coverage is selected, please specify the date coverage should begin.

Date Monthly Coverage Ends

If monthly coverage is selected, please specify the date coverage should end.

University of Alaska Anchorage