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Graduate Assistant/Fellow Health Insurance Enrollment Form

UAA Student ID Number = 8 characters.

If no middle initial, enter N/A

MM/DD/19__

Choose M for male, and F for female. Other options are not available at this time.

Where do you receive your mail now? Please include Street, Circle, Drive, Avenue, or PO Box, etc.

Choose: Apt #, building #, suite #, space #, etc.

2 character state abbreviation only; e.g. AK, WA, etc.

99508 (five digits only)

Format: (XXX) XXX-XXXX

Dates of Coverage: 
Fall: August 24 to January 4 (following year)
Spring: January 5 to May 16
Spring/Summer: January 5 to August 24
Summer: May 17 to August 24

Please enter only the time period listed (fall, spring, spring/summer, or summer) from your current contract letter.

Enter the coverage period listed on your contract letter

Not submitting your contract letter will delay health insurance benefits. to the Graduate School.

Check the source of your enrollment

All teaching assistants must have current FERPA certification.

When did you complete your most recent FERPA certification training? Enter date above.

Please check your type of residency