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Fillable 2011_335_2_ContinuationEnrollment_v3_Layout 1

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PROCESSOR STAMP DATE RECEIVED HERE UNITEDHEALTHCARE INSURANCE COMPANY CONTINUATION ENROLLMENT FORM FOR GRADUATE STUDENTS AND THEIR DEPENDENTS UNIVERSITY OF ALASKA FAIRBANKS PRIMARY INSURED Complete information below for Student. SOCIAL SECURITY #: LAST (FAMILY) NAME: GENDER: 2011-335-2 OR STUDENT ID #: FIRST (GIVEN) NAME: MIDDLE INITIAL: ___ / ___ / ___ MONTH DAY YEAR PERMANENT U.S. ADDRESS - House/Building...
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