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Only Special Enrollment is available for Students

Check with your campus student health advisor before applying

  Notice: Social Security Number is required for US Citizens only.
  Notice: Please use a current email address, as an email confirmation will be sent to that address when you complete the application.
* Social Security Number * University Colleague ID
* Name First Last Middle Initial
* Gender * Birth Date
* Expected Graduation Date * Are you a US citizen?
Permanent Address
* Country Country is required. If you choose a non-US country,
State & Zip Code are not required.
* Street Line 1 Street Line 2
* City * State
* Zip Code - #####-#### * Email Address
Address during Semester
* Country Country is required. If you choose a non-US country,
State & Zip Code are not required.
* Street Line 1 Street Line 2
* City * State
* Zip Code - #####-####
* What school are you planning on attending? * Do you use tobacco?
Insurance Plan Options
  • Choosing an insurance plan option is required
  • A Tobacco user is charged an additional fee of 20% of the premium
  No Regular Plans available
Enrollment currently closed
Single Under 25
Single Age 25 - 29
Single Over 30
Optional Intercollegiate sports coverage - students only
Intercollegiate Football
All Other Sports
Special Coverage Plan Options
Special Short Term Coverage is only available to students who are participating in a university sponsored program outside of the regular semester term.
Do not select this coverage if attending regular semester classes.
Enter the Start and End dates of your time on campus instead of selecting an Insurance Plan Option above.
Coverage rates are prorated based on your attendance dates.
After review of your application, you can see your premium amount and payment information in about 5-10 days via SDePay in WebAdvisor.
Short Term Coverage Select Period: to
Special Late Arrival Coverage is only available to students who arrive on campus after a regular term has started, are attending regular term classes and arrive after the Insurance Plan Option for that term is no longer open.
Enter the Start date of your arrival on campus.
After review of your application, you can see your premium amount and payment information in about 5-10 days via SDePay in WebAdvisor.
This coverage is only effective until the start of the next regular spring or fall term. You also need to enroll in insurance for any future terms you will be attending clases.
Late Arrival Coverage Select Start Date:
Previous Coverage
* Have you previously been covered by a health insurance policy?
If yes, please list the name of the Insurance Company that provided your insurance:
* Have you lived in a country with national health plan?
If yes, which country?
Notice to Student: Coverage will be effective the date identified by the plan and confirmation of enrollment. By signing, the student acknowledges the following:
  1. He/She has carefully read the brochure and elects to enroll as indicated on this enrollment card
  2. Rates are not pro-rated other than as listed on this enrollment card
  3. He/She meets the eligibility requirements for this coverage as described in the brochure
  4. If it is later determined that the student is not eligible, the premium will be refunded
  5. If Special Short Term or Late Arrival coverage was selected you can view your premium amount in about 5-10 days via SDePay in WebAdvisor
  6. When you click the Enroll for Insurance button below, premium charges will be applied to your university tuition and fees bill in about 5-10 days and can be paid via SDePay in WebAdvisor
For more information please review the Master Policy.
* Student's Signature Date 04/20/2014