Student Health Insurance Enrollment Form

Student Health Insurance Enrollment
Fall 2009 - 2010

The Health Services office administers the student health insurance program. Health insurance is mandatory for domestic full-time students (undergraduates taking at least 12 hours; graduate students taking at least 9 hours, Kent Law at least 12 hours),residents of IIT residence halls and all students studying on F1 or J1 visas.

The deadline for enrolling in the Student Health Insurance Plan for the Fall 2009 term is September 1, 2009.

By completing the following form you are enrolling in the Student Health Insurance Plan at the Illinois Institute of Technology for the current semester and giving authorization for us to charge to your student account the necessary fees for student health insurance. The student health insurance plan expires August 13, 2010.

First Name:
Last Name:
Middle Initial:
CWID:	(123-45-678)
Status
Street Address:
Daytime Phone:	(123-456-7890)
Evening Phone:	(123-456-7890)
E-mail Address:

	Please enroll me in the insurance plan at a cost of $850.00	Coverage Info

I understand that I am enrolling in the IIT Student Health Insurance Plan beginning with the Fall 2009 semester and that my student account will be billed $850. Please enroll me in the insurance plan.

I understood the statement above: Date: (MM-DD-YYYY)