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Get and Sign Ucb Cares Program Enrollment Form 2018-2022
MALE
OTHER
Please check appropriate box:
SINGLE
MARRIED/DOMESTIC PARTNER
Please check appropriate box:
DOMESTIC
INTERNATIONAL
PLEASE LIST DEPENDENTS TO BE INSURED BELOW. DEPENDENT COVERAGE IS AVAILABLE ONLY IF THE STUDENT IS ALSO ENROLLED IN SHIP. Please see the Benefit Booklet for
complete benefits and contact information. Dependents must be enrolled on the date the student is enrolled or within 31 days of a qualifying event.
LAST / SURNAME
FIRST NAME
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