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UNC Chapel Hill
UNC

2019-20 Health Insurance Budget Adjustment Request

* Denotes required
Student's Information
Health Insurance Enrollment Information

By submitting this form, you are requesting your financial aid budget for the Academic Year be updated due to enrolling in the UNC System Student Health Insurance Plan (StudentBlue).

In order to complete this form, you must have and enter the confirmation number that you received from Campus Health when you enrolled for the Academic Year you indicate. Our Office will also confirm billed charges on your student account prior to adjusting.

This form cannot be submitted until you have enrolled in the UNC System Student Health Insurance plan.

For which semesters during the 2019-2020 Academic Year will you be enrolled in the UNC System Student Health Insurance plan?
For which semesters during the 2019-2020 Academic Year will you be enrolled in the UNC System Student Health Insurance plan?
Student's Information Certification and Digital Signature
Student's Certification Statement: By typing my name and checking the box below, I certify by electronic signature that I am the above named student and, to the best of my knowledge, the information I have provided on this form and any documentation I am providing to support this information is true and complete.
Student Certification
Student Certification
Date Signed
Date Signed