Category: Benefits Title: Enrollment Form for Graduate Student Employees/Fellowes and Their Dependents Type: For RF/Student Employees   Format: Adobe Acrobat (PDF)1 Microsoft Word/Excel Form: Size: 300 KBytes 69 KBytes Form Date: 08/06 08/06 Related Link: http://www.stonybrook.edu/hr/benefits/rf/student.shtml Special Notes: Instructions and Examples: To process your health insurance enrollment application, you must attach a copy of the following items for yourself and each person you wish to cover. Your enrollment application will not be processed if the following items are not attached. You MUST make your own copies and attach it to your enrollment application. For Individual coverage a student must submit the following items: Birth Certificate or Passport Social Security Card If student is enrolling spouse or child they will need to submit the following items: Birth Certificate or Passport Social Security Card Marriage Certificate (if applicable) OR I-20 for International Students Proof of full-time student status (for your dependents 19-25 years old) Proof of Support/Dependence for other children (if applicable) Proof of Disability (if applicable) COPIES WILL NOT BE MADE IN THE INSURANCE OFFICE Revision History: 03/07 08/06 01/05 01/04 08/02

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