Health Insurance Verification : Welcome Packet Forms : Student Life

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.

Cancel and Go Back

2012-2013

Student Status
Please choose:	New Student Returning Student
Student Information
Full Name:
Student ID Number:
Birth Date:
Gender:
Cell Phone:
Family or Guardian Emergency Contact
Full Name:
Relationship to student:
Phone:
Cell Phone:
Health Insurance Declaration
Option 1	I have no health plan. I must enroll with Fairmont Specialty Student Health Insurance at: $1,085 per year. 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.
Option 2	I want Fairmont Specialty Student Health Insurance Plan as a Supplement to my insurance. 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.
Option 3	I am waiving my participation because I am covered by the policy described below. 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.
Health Insurance Information
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.

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Online Welcome Packet Forms

Required Document for Enrollment

Health Insurance Verification