DEPARTMENT OF _____________________ …

                         DEPARTMENT OF _____________________

                                         University of Utah

 DECLARATION TO ACCEPT OR DECLINE SUBSIDIZED STUDENT HEALTH INSURANCE
                                __________ SEMESTER 200___

------------------------------------------------ Decline -------------------------------------------------

        I decline health insurance coverage through the GM Southwest Graduate Student
        Health Plan.

SIGNATURE: __________________________________ DATE: __________________

NAME (please print): _____________________________________________________

STUDENT ID NUMBER: _________________________________________________

------------------------------------------------ Accept --------------------------------------------------

         I wish to enroll in the GM Southwest Graduate Student Health Plan


Please check the appropriate boxes below:

        I want to be covered in an individual student plan

        I would like to purchase insurance for:              (Check any and all boxes that apply)

                            spouse            one child            children

I certify that I am a fully matriculated graduate student in good standing with at least a
3.0 GPA and am registered for at least 9 credit hours for __________ Semester 200___. I
am appointed as either a TA or RA and am receiving a full (100%) tuition benefit.

I understand that if I fail to meet these requirements I will be required to pay the full cost
of my insurance for __________ Semester 200___.

My signature indicates that I understand and meet these requirements, and accept the
coverage.

SIGNATURE: __________________________________ DATE: __________________

NAME (please print): _____________________________________________________

STUDENT ID NUMBER: _________________________________________________