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.

99508 (five digits only)

Format: (XXX) XXX-XXXX

Dates of Coverage: 
Annual = 8/25/2020 - 8/24/2021
Fall = 8/25/2020 - 1/4/2021
Spring = 1/5/2021 - 5/16/2021
Spring/Summer = 1/5/2021 - 8/24/2021
Summer = 5/17/2021 - 8/24/2021

Please enter only the time period listed (fall, spring, summer, or annual) 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 last complete FERPA certification training? Enter date above and email copy of your certificate to the Graduate School..

Please check your type of residency