Online Claim Form

Monday, November 23, 2009

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Dates and Premiums

Student Insurance Plan
Coverage Periods

Summer 2009	5/16/2009-8/21/2009
Fall 2009	8/22/2009-1/15/2010
Spring 2010	1/16/2010-5/14/2010
Summer 2010	5/15/2010-8/20/2010

Enrollment/Change Periods

Summer 2009	5/18/2009-6/22/2009
Fall 2009	8/24/2009-9/23/2009
Spring 2010	1/19/2010-2/22/2010
Summer 2010	5/17/20010-6/22/2010

Extension Enrollment

Summer 2009	4/13/2009-6/22/2009
Fall 2009	7/13/2009-9/23/2009
Spring 2010	12/01/2009-2/22/2010
Summer 2010	4/12/2010-6/22/2010

Premiums Per Semester
Fall 2009 - Summer 2010

	Undergrad	Graduate
Student	$206	$292
Spouse	$849	$1181
Children	$392	$589

Premiums Per Semester
Fall 2008 - Summer 2009

	Undergrad	Graduate
Student	$197	$279
Spouse	$836	$1164
Children	$386	$580

To begin filling out the form, please login using your Enterprise ID and password. The form is available only to students. If you do not have an Enterprise ID or if you are no longer a student, please download the form here and submit to the Student Insurance Office.

If your address information is incorrect or out of date as it appears on the form, please update using the UI-Integrate Self Service application.

Claim Form

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