Student Health Insurance Plan Form printable pdf download

UC DAVIS STUDENT HEALTH INSURANCE PLAN (UC SHIP)

Cancellation and Refund Request

If your student registration status changes on or after the first day of the term, your UC SHIP coverage will continue to

the end of the term, and your UC SHIP fee is not automatically refunded. In certain extraordinary circumstances, you

may request cancellation of your UC SHIP insurance coverage and a refund of your UC SHIP fee. Cancellation of coverage

and refund of the UC SHIP fee are granted at the sole discretion of the UC SHIP Administrator at Student Health and

Counseling Services (SHCS). Notification of approval or denial will be sent to your UC Davis email account.

Please provide the following information:

Date: ______________ Student ID Number: ____________________ Phone:______________________

Name: ________________________________________ E mail: _________________________________

Street Address: ________________________________________________________________________

City, State, ZIP: ____________________________________________

Last Registered Class Status: (Check only one)

____ Undergraduate

____ Graduate (Quarter)

____ Graduate (Semester)

Reason for Registration Status Change:

! DISMISSED – Quarter/Semester Dismissed: ________________ Effective Date: _____________

! OTHER – Quarter/Semester Dismissed: ________________

Effective Date: _____________

Please Describe: _______________________________________________________________________

Please initial all that apply:

____ I have not obtained any medical services or pharmaceuticals that could be charged to my UC SHIP insurance since

_____________ (start date of current academic term).

____ I have not filed and will not file any claims to UC SHIP for medical services or pharmaceuticals obtained on or after

______________ (start date of current academic term).

____ I understand that I may not re-enroll in UC SHIP during the current academic term, and that I will not be eligible for

UC SHIP in the future unless I return to active student status at UC Davis.

STUDENT SIGNATURE: _______________________________________ DATE: _______________

__________________________________________________________________________________________________

! Your UC SHIP cancellation and fee refund request is approved, effective date ____________. Your student

account will be credited.

! Your UC SHIP cancellation and fee refund request has been denied. Your UC SHIP coverage will continue through

______________ (last day of current term).

Reason for Denial: ______________________________________________________________

_____________________________________________________

Date: __________________

Authorized Signature (UC SHIP Administrator)

Student Health Insurance Plan Form