Use this form to enroll in Southern's student health insurance plan or request a waiver. Students who are 18 and older may use this online form. Otherwise, please submit the printed PDF.
Undergraduate students taking six or more hours (three or more during any summer session) or living in university housing are automatically enrolled and charged for insurance unless they request a waiver below.
First, middle, and last name
Student ID number
Date of birth
Local mailing address
Select . . .
Select the dates for which you need coverage.
Insurance is billed at the beginning of each session. Select all applicable terms. If you will not be enrolled in the summer but want summer coverage, choose "Full Year" or "Winter and Summer." This insurance is effective throughout the United States.
To add a spouse or children to your policy, select the dates and provide the information below for each person you wish to include.
To qualify for a waiver, please provide your policy information as applicable.
Primary insured (policy holder)*
Policy ID number
Insurance company phone*
Claims address (If provided)
Students (or parents) are responsible for verifying the scope of private insurance plans.
The University Health Center can provide a walk-out statement, but does not bill private insurance.
I attest that this information is valid and accurate. I understand that willful falsification of information is a violation of the university Student Commitment to Responsible Conduct and that all information on this page is subject to audit by Southern.
There's more information on the Risk Management student insurance page or at uhcsr.com/southern. You may also call Risk Management at 423.236.2566.