WWAMI/Graduate Health Insurance Enrollment Form

UAA Student ID Number = 8 characters. WWAMI students do not use your UW ID #

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 = 8/25/2019 - 8/24/2020
Fall = 8/25/2019 - 1/4/2020
Spring = 1/5/2020 - 5/16/2020
Spring/Summer = 1/5/2020 - 8/24/2020
Summer = 5/17/2020 - 8/24/2020

UAA Graduate Assistants/Fellows: enter only the time period listed (fall, spring, summer, or annual) from your contract letter.

WWAMI Students: Choose Monthly coverage ONLY if NOT selecting Annual coverage. Monthly coverage begins on the first of the selected month and ends on the last day of the final month. Enter Coverage Period then skip to Months of Coverage.

WWAMI Students: select either annual or monthly coverage; drop down to "WWAMI Only" information next.

How will you submit a copy of your signed contract letter to the Graduate School? WWAMI select N/A

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

Enter total number of months of coverage selected.

Coverage must begin on the first day of the month selected. Enter date below.

Coverage must end on the last day of the month selected. Coverage cannot extend beyond August 24, 2020. Enter date below.