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Get Student Dependent Filable Form

ENTS www.ucop.edu/ucship Wells Fargo Medical ID# STUDENT S NAME STUDENT ID # Last Name (Family Name) First PERMANENT U.S. MAILING ADDRESS DATE OF BIRTH Street City State PHONE # SPOUSE/ DOMESTIC PARTNER MI Mo. Day Year Apt. # Zip E-MAIL ADDRESS LIST DEPENDENTS TO BE INSURED BELOW. DEPENDENT COVERAGE IS AVAILABLE ONLY IF THE STUDENT IS ALSO INSURED. Please note that benefits and coverage levels for dependents differ from those of st.

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