Required Document for Enrollment

Health Insurance Verification

This form is due by December 10, 2012. Non-compliance may result in a $250 fine.

Students enrolled in nine or more units per semester are required to have health insurance. The University strongly recommends that Parents and Students review their health insurance policies to ensure their policy provides coverage/benefits to the health care facilities located in the Redlands/Inland Empire area. All currently enrolled students can use the Student Health Center regardless of their insurance. Medical visits are free; however, there is a charge for lab tests, immunizations, and prescription medications. Student Health Center does not process or bill insurance.

2012-2013

Please choose:

Fall $434 for coverage from 8/13/2012 – 1/6/2013 and Spring $651 for coverage from 1/7/2013 – 8/12/2013
Read the information about the plan in the accompanying brochure and sign below.

I’ll be billed like Option 1, above. Please remember to Fax, scan/email, or mail the front/back of the insurance card (or front page of your policy) after completing the form. Be sure to include the Student name and ID #. Call the Health Center with any questions at (909) 748-8021.

Please remember to Fax, scan/email, or mail the front/back of the insurance card (or front page of your policy) after completing the form. Be sure to include the Student name and ID #. Call the Health Center with any questions at (909) 748-8021.

Since you have selected option 1 above, you do not need to fill out this section.
Signature
You are under 18 and must print this form below.
 

Are you sure you would like to cancel and go back?