STU-DENT REGISTRATION FORM FOR NYU STUDENTS

Please note: This form is only for use by NYU Students. If you are not an NYU student and wish to enroll in the plan, please use this form.

2023-2024
New ($275)  Renewal ($225)
Note: Effective September 1, 2015, eligible graduate employees covered under the UAW Local 2110/NYU collective bargaining agreement will be covered by the Stu-Dent Plan for NYU students at no cost.
Male  Female
Freshman  Sophomore  Junior  Senior  Grad Student
Address Information
Partner Information
Yes  No
New ($250)  Renewal ($205)
Male  Female
Address Information
(if different from above)
Dependent Information
Yes  No
New ($90)  Renewal ($90)
Male  Female
Address Information
(if different from above)
Additional Dependent Information
Yes  No
New ($90)  Renewal ($90)
Male  Female
Address Information
(if different from above)
 x $275.00 =  
 x $225.00 =  
 x $105.00 =    

If you enrolled through your bursar account, corrections for StuDent Dental Plan can ONLY be made during the designated enrollment period between June 22 and September 30, 2022. NO FURTHER CORRECTIONS CAN BE MADE AFTER THE ENROLLMENT DEADLINE unless there are qualifying circumstances.