WWAMI United Healthcare Enrollment Form

If you see this don't fill out this input box.

WWAMI students are invited to enroll in the UAA Graduate Student Healthcare Benefits Plan. Students may enroll for the academic year or by the month.

UAA Student ID Numberrequired

Provide UAA Student ID Number. (Do not use your UW ID Number.)

Last Namerequired

First Namerequired

Middle Initial required

If you do not have a middle name, please enter N/A

Date of Birthrequired

MM/DD/YYYY

Genderrequired

This insurance requires a selection of M for male or F for female.

Current Street Addressrequired

Current Street Address (continued)

Choose: Apt #, Building #, Suite #, Space #, etc.

Cityrequired

Staterequired

Zip Coderequired

Preferred Email Addressrequired

Telephone Numberrequired

Format: (XXX) XXX-XXXX

Period of Coveragerequired

AnnualMonthly (See next box)

Choose either Annual or Monthly

Date Monthly Coverage Begins

Date must be the first day of the month.

Date Coverage Ends

Date must be the last day of the month.

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