Indiana University
INTERNATIONAL STUDENT
INSURANCE PLAN
Dependent Qualifying Life Event Enrollment Form
2023-2024 Academic Year
A qualifying life event is a change in your situation that makes you and/or your dependent(s) eligible to enroll in the student health insurance plan outside of the initial enrollment period.
Student Qualifying Event: Contact the IU Student Insurance Office (studenhc@iu.edu)
Dependent Qualifying Event: use this form to enroll dependents in one of the situations described below.
Loss of Other Coverage:
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Required Documentation: loss of coverage letter that includes the dependent's name and last day of coverage
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Deadline: 30 days from the last day of coverage in the prior plan
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Effective Date of Coverage: the first day without coverage in the prior plan
Marriage to Student:
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Required Documentation: copy of the marriage certificate
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Deadline: 30 days from the date of marriage
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Effective Date of Coverage: date of marriage
Birth or Adoption:
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Required Documentation: official documentation of the birth or adoption
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Deadline: 30 days from the date of birth or adoption
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Effective Date of Coverage: date of birth or adoption
Change in Residence (entry into the US or moving from coverage area):
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Required Documentation: Identification page of Passport and page with U.S. entry date stamp or I94 form if moving to the US or documentation of move from prior plan's coverage area if relocating within the US and losing access to coverage.
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Deadline: 30 days from the entry into the US or move from the coverage area
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Effective Date of Coverage: date of entry into the US or move from the coverage are
