STU-DENT REGISTRATION FORM FOR NYU STUDENTS

Please note: This form is only for use by NYU Students. If you are not an NYU student and wish to enroll in the plan, please use this form.

2018-2019 2019-2020
New ($240)  Renewal ($195)
Note: Effective September 1, 2015, eligible graduate employees covered under the UAW Local 2110/NYU collective bargaining agreement will be covered by the Stu-Dent Plan for NYU students at no cost.
Male  Female
Freshman  Sophomore  Junior  Senior  Grad Student
Address Information

Partner Information
Yes  No
New ($240)  Renewal ($195)
Male  Female
Address Information
(if different from above)

Dependent Information
Yes  No
New ($85)  Renewal ($85)
Male  Female
Address Information
(if different from above)

Additional Dependent Information
Yes  No
New ($85)  Renewal ($85)
Male  Female
Address Information
(if different from above)

 x $240.00 =  
 x $195.00 =  
 x $85.00 =