Student Name: / Student ID Number:
Last / First / Middle
Student Phone: () / Student E-mail Address:
Mailing Address / City / State / Zip Code
Department/Program: / School:
Degree: Ph.D. Master’s
I have enclosed a check (payable to "UC Regents") in the amount of $1,763.92as my Summer 2018 payment. Check No.
Or, my department will be charging this amount from Acct/Fund: - -via payment to Wells Fargo through the voluntary enrollment process
Quarter/Year you intend to first enroll: Fall
Year
I HAVE PREVIOUSLY (check all that apply):
Submitted an application for graduate study at UCI.
Been admitted to graduate study at UCI.
Submitted my Statement of Intent to Register. / I AM CURRENTLY (check one):
Planning to enroll in Summer Session
Planning to work at UCI with the professor indicated
NOTE: If you are an international student, you must have the International Center Office (G302 UCI Student Center) complete the "International Center" section on the second page of this form prior to submitting this form for final approval in the Graduate Division. This is due to specific visa requirements.
I understand that by enrolling in this summer GSHIP option that I must also enroll as a full-time graduate student during this upcoming academic year beginning with fall quarter. I also understand that I will not be able to waive out of the GSHIP program at any time during this next academic year.
STUDENT SIGNATURE: / DATE: / / /
Please Note: Enrollment in first summer GSHIP is a two-step process. Students must be approved by the Graduate Division and enroll and pay the premium through the voluntary enrollment process:
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UCI Graduate DivisionRevision date: 05/04/2018
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DEPARTMENT/FACULTY / Prior to completing this section, ensure that you have read, understood, and concur with theinformation provided by your student on page 1 of this form. After completing this section, returnthe form to the student or to the Graduate Division.
I certify that this student is working on graduate related research or coursework on the UCI campus during the summer immediately prior to their matriculation and enrollment this upcoming Fall.
AGREE
DISAGREE
Principal Investigator (print name, then sign and date) / Date
INTERNATIONALCENTER / International Students only: Please obtain approval from UCI's International
Center (G 302 UCI Student Center) and then forward the completed form to the
Graduate Division (120 Admin., Attention: Ruth Quinnan).
APPROVED STATUS
NOT APPROVED
International Student Advisor (please print name, then sign and date) / Date
GRADUATE DIVISION
APPROVED – QUALIFICATIONS REVIEWS
NOT APPROVED – DOES NOT MEET CRITERIA
Ruth Quinnan or Designate (print name, then sign) / Date
UCI GSHIP COORDINATOR / UCIStudentHealthCenter
PROCESSED FOR COVERAGE EFFECTIVE ______
Date
STUDENT NOTIFIED VIA: ______
Date
UCI GSHIP Coordinator (print name, then sign) / Date
UCI Student Health
501 Student Health Center
ZotCode: 5200
UCI Graduate DivisionRevision date: 05/04/2018
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BACKGROUND INFORMATION FOR COMPLETING FIRST SUMMER GSHIP PETITIONFREQUENTLY ASKED QUESTIONS
Why do I need to do this?
As a courtesy, UCI has made special arrangements with our graduate student health insurance carriers for you to begin your healthcare
coverage before the usual fall quarter start date. This alternative is an option to other coverage you may wish to explore. Coverage is not automatic. Rather, it requires the completion and submission of the two pages of theFirst Summer GSHIP Petition and, once approved, you must enroll and pay the premium through the voluntary enrollment plan.
What are the details of the summer coverage I would be eligible for?
Information is available on the Student Health Center website at:
The summer coverage will be identical to the coverage during the current plan year. For full details of plan coverage, please visit the SHC website at: Please read the plan details prior to deciding to enroll. Some pre-existing medical condition clauses do exist.
Why is the summer rate a fixed rate, irrespective of when I enroll during the summer?
By agreement with the insurance carrier, the agreed to premium represents the quarterly rate for the prior academic year. Just as in the
academic year, prorated amounts are not an option. It is the student’s decision whether to enroll in this special summer insurance program or choose another plan that might be a better personal choice for them.
How long should I allow for processing of this request/petition?
Once this form is received in the Graduate Division, please allow up to three working days for final processing. The Graduate Division will contact you at the phone or e-mail information you provided if there are any questions. The UCI GSHIP Coordinator will notify you of the effective date of your coverage once approved.
How will I be notified of my effective date once coverage is approved?
You will be contacted by the UCI GSHIP Coordinator once your coverage has been approved by the university, and your voluntary enrollment form and payment have been received and processed by Wells Fargo insurance services. Once approved, the coverage will be effective immediately.
If I will not be working/studying at the UCI campus during the summer, am I still eligible to enroll?
NO, this special summer coverage is only available for students who will be physically located at the UCI campus.
UCI Graduate DivisionRevision date: 05/04/2018
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