PLEASE COMPLETE THIS FORM
IN BLOCK LETTER PRINT
USE BLACK INK
UNITED HEALTHCARE INSURANCE COMPANY
ENROLLMENT FORM FOR DOMESTIC STUDENTS
AND THEIR DEPENDENTS
SEATTLE PACIFIC UNIVERSITY
2009-1462-1
SOCIAL SECURITY #
-
-
or
SCHOOL ID#
PRIMARY INSURED
STUDENT NAME:
Last (Family) Name
First (Given) Name Middle Initial
GENDER: ❑ Male ❑ Female DATE OF BIRTH: ______ - ____ - ______ EXPECTED DATE OF GRADUATION: ______ - _____
Check one
Month
Day
Year
Month
Year
MAILING ADDRESS:
House/Building Number and Street Name
-
Apt. or P.O. Box # or Rural Route City County State ZIP
Code
PERMANENT ADDRESS:
House/Building Number and Street Name
-
Apt. or P.O. Box # or Rural Route City County State ZIP
Code
TELEPHONE # - -
E-MAILADDRESS: ______________________________________________
Complete information below for Dependents to be insured. Dependent coverage is available only for Students insured under the Plan.
SPOUSE: - -
❑ Male ❑ Female
Date of Birth : - -
Social Security Number (Check One)
Month
Day
Year
First (Given) Name
M/I
Last (Family) Name
CHILD: - -
❑ Male ❑ Female
Date of Birth : - -
Social Security Number (Check One)
Month
Day
Year
First (Given) Name
M/I
Last (Family) Name
CHILD: - -
❑ Male ❑ Female
Date of Birth : - -
Social Security Number