GeoBlue Worldwide Health Insurance Enrollment Form

Fields with asterisks (*) are required.

Gender *

Program Information

College/School Affiliation *


I wish to enroll for insurance under the terms of Wayne State University's master insurance policy with GeoBlue Worldwide Health Insurance for Higher Education.

The stated premiums are valid until 12/31/2018. I certify that I meet eligibility described in the attached brochure. I acknowledge that benefits will not apply to treatment arising from pre-existing medical conditions. Payments must be made via website through the online payment system. Total premium for Full Term coverage must be paid in U.S. dollars at the time application coverage is made (CASH/CHECKS ARE NOT ACCEPTED).

In regards to payment *