George Washington University
STUDENT HEALTH INSURANCE PLAN

Qualifying Event Enrollment Form
2020-2021 Academic Year

 

A qualifying event is an event like losing health coverage, getting married, having a baby, or moving. These changes can make you and/or your dependents eligible for a special enrollment period, allowing you to enroll in the student health insurance outside the open enrollment period. 


You can use this form to enroll you and/or your eligible dependents in the GW student health insurance plan. Please contact University Health Plans at 800-437-6449 for eligibility if you have a qualifying event not listed below.

Loss of Other Coverage (losing health coverage through employer, parent's plan, or Medicaid)

Changes in Household (getting married or divorced, having a baby or adopting a child, or death in the family)

Changes in Residence (entry into the US or moving out of existing coverage area)


All qualifying events require documentation to provide proof of your qualifying event. If you have questions about the documentation required, please contact University Health Plans at 800-437-6448 before you submit your enrollment form. 

Enrollment Deadline: The qualifying event enrollment form, payment, and required documentation must be received within 31 days from the qualifying event date. 

 (MM/DD/YYYY)