Online Form

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Campus Location

Student Status

Choose Coverage Dates

Student Information


Instructions on printing your insurance ID card will be emailed to this address.

Spouse and Dependents

Are you adding a spouse to your insurance plan?

Are you adding dependents to your insurance plan?

Relationship Gender Social Security Number Last Name First Name Middle Initial Date of Birth
Child 1
Child 2
Child 3
Child 4

Premium Selection

A brief summary of the coverage and services offered are:

  • Unlimited Maximum Benefit for Covered Expenses
  • Coverage available for eligible Dependents
  • $500 Deductible for Preferred Providers per Insured Person, per Policy Year 
  • Covered Medical Expenses for Preferred Providers are payable at 80% after deductible
  • $25 In-Network Physician Visit Copay
  • $20 Tier 1 Copay / 30% Member Coinsurance Tiers 2-3 Prescription Drug Benefit
  • For more details, click here.

Payment is due in full at the time of enrollment. Optional Dental or Vision Coverage is available ONLY until the enrollment deadline of September 20th of each plan year and must be purchased on an annual basis. It is the student’s responsibility for timely renewal payments whether or not a renewal notice is received.

SELECTED COVERAGE PERIOD: Summer Coverage , 5/1/2023 -7/31/2023

To change your coverage period go back to the previous page.

What is a premium?

An insurance premium (sometimes referred to as the rate) is the amount of money you are charged for active coverage.

What is a deductible?

A deductible is the amount you pay before the insurance carrier will cover any remaining eligible expenses.

What is a copay?

A copay is a set portion of a total bill you are required to pay. This often refers to a physician office visit where the copay is your responsibility.

Learn More

Selected Premium Total


Payment Information

Premium total includes a 2.5% processing fee.

Visa / Mastercard / Discover Cards Accepted Only

*CID code is the last, 3-digit number printed on the signature strip on the back of your card



Your card will not be charged until you click submit.