Submit materials to:
Graduate Division
Attn: Ruth Quinnan
120 Aldrich Hall
Zot Code 3180
(949) 824-4611
FIRST SUMMER GSHIP PETITION:
LETTER OF UNDERSTANDING
FOR GRADUATE STUDENTS
New incoming graduate students who will be performing research or enrolling in UCI courses during the Summer immediately preceding
their fall matriculation into a UCI graduate program are eligible to enroll in GSHIP’s comprehensive medical, dental and vision insurance
program. Please complete this top page and submit this petition first to your home department office/faculty. After your petition has been
approved by your department/Principal Investigator, submit this form to the Graduate Division, 120 Aldrich Hall for processing. You will
be notified if/when this petition is approved. Once approved it will be forwarded to the Student Health Center.
STUDENT
Student ID Number:
Student Name:
Last
Student Phone: (
First
)
Student E-mail Address:
Mailing Address
City
State
Ph.D.
Zip Code
School:
Department/Program:
Degree:
Middle
Master’s
I have enclosed a check (payable to "UC Regents") in the amount of $757.88 as my Summer 2015 payment. Check No.
Or, my department will be charging this amount from Acct/Fund:
enrollment process
Quarter/Year you intend to first enroll:
-
-via payment to Wells Fargo through the voluntary
Fall
Year
I HAVE PREVIOUSLY (check all that apply):
I AM CURRENTLY (check one):
Submitted an application for graduate study at UCI.
Planning to enroll in Summer Session
Been admitted to graduate study at UCI.
Planning to work at UCI with the professor indicated
Submitted my Statement of Intent to Register.
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:
http://www.shs.uci.edu/health_insurance_privacy/insurance.aspx#voluntary
(continued on next page)
UCI Graduate Division
Revision date: 04/16/2015
Page 1 of 3
DEPARTMENT/
FACULTY
Prior to completing this section, ensure that you have read, understood, and concur with the
information provided by your student on page 1 of this form. After completing this section, return the
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)
INTERNATIONAL CENTER
Date
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)
UCI GSHIP COORDINATOR
Date
UCI Student Health Center
PROCESSED FOR COVERAGE EFFECTIVE
__________________
Date
STUDENT NOTIFIED VIA: _______________ __________________
Date
UCI GSHIP Coordinator (print name, then sign)
UCI Student Health
501 Student Health Center
ZotCode: 5200
UCI Graduate Division
Date
Revision date: 04/16/2015
Page 2 of 3
BACKGROUND INFORMATION FOR COMPLETING FIRST SUMMER GSHIP PETITION
FREQUENTLY 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 the First 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:
http://www.shs.uci.edu/health_insurance_privacy/insurance.aspx#voluntary
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: http://www.shs.uci.edu. 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 Division
Revision date: 04/16/2015
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