Rinker Graduate - Student Health Request Form 2020-2021
Student Business Services JUNE 2020
TO: Student Business Services Office
STUDENT: _________________________________
(Print Full Legal Name)
ID #:
I hereby request and authorize Chapman University to charge my student account for the Student Health
Insurance plan for the academic year. Fees are assessed on a trimester basis, after class enrollment has
been verified, and will be billed for the Fall, Spring, and Summer trimesters.
International Students, and certain Rinker programs, are automatically billed for Student Health Insurance.
A form will not be required, in these cases.
I UNDERSTAND THAT I MUST BE REGISTERED IN 6 UNITS OR MORE TO PURCHASE STUDENT
HEALTH INSURANCE THROUGH CHAPMAN UNIVERSITY.
Select the options below:
Student Health Insurance
$2,040 per year ($680 per trimester)
SIGNATURE: DATE:
IMPORTANT INFORMATION: FOR NEW ENROLLEES
I understand that the Health Center Office requires this form back, as soon as possible, in order to
provide services to me.
I understand that I must be registered in 6 units or more to purchase Student Health Insurance through
Chapman University.
I acknowledge that my student account has a domestic (non-P.O. Box) address on file. Please note, if we
are missing this information, coverage cannot be reported.
I acknowledge that my student account has a valid Social Security Number and or ITIN, if I am non-
international student.
I understand that coverage will be provided for the academic year and a new request form will be required
for any subsequent years.
CHAPMAN UNIVERSITY USE ONLY:
Name ________________________Date ______________ Local Address ____ SSN____ DOB ____Gender _____
Checked box for Fall _____ Checked Box for Spring ____ Checked Box for Summer ______
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signature
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