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Personal Information Form

This Personal Information Form is to be used by students who are automatically enrolled in the Student Health and Dental Plan(s), and wish to activate the coverage for such plans. This form should be submitted as soon as possible. DO NOT WAIT UNTIL YOU NEED TO ACCESS THE COVERAGE TO SUBMIT THIS FORM , or your claim will be delayed.

This form is required for you to provide the personal information necessary to activate insurance coverage. You must complete and submit this form to authorize the use of your information for the purpose of providing coverage under the plans. The assessment of the fees establishes your coverage, but activation cannot occur until the eligible student has completed and submitted this form.

Please read and agree to the Terms & Conditions prior to submitting your Personal Information Form.

Student Information

Date of Birth
Phone Number
Program Start Date
For your convenience, after this form has been submitted, the information is on file each subsequent consecutive school year that you are assessed the plan fees. If there is a semester where you are not eligible, then you will have to resubmit this form during the next semester of eligibility.

Should you have any questions regarding the Personal Information Form please contact the SAMRU Student Benefits Plan Ofice prior to submitting this form.

Enrolment is not guaranteed by submitting this form;The Student must be eligible for the program.

Service Members

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