Uben100: Fill out & sign online

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01. Edit your uben100 online

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Click ‘Get Form’ to open the uben 100 in the editor.
Begin by filling out your personal information in Section 1. Enter your name, Social Security number, and former campus location clearly. Ensure that your home and mailing addresses are accurate.
In Section 2, select the action you wish to take regarding your medical, dental, or legal plan. Choose 'Enroll' if you are adding coverage or 'Change' if you need to modify existing plans.
Proceed to Section 3 where you will indicate your desired medical, dental, and legal plans. Check the appropriate boxes for enrollment or cancellation as needed.
In Section 4, provide details about eligible family members who may be included in your plan. Make sure to enter their relationship codes and Social Security numbers accurately.
Finally, review all entered information for accuracy before signing in Section 5. Remember that electronic signatures are acceptable on our platform.

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