Brandeis University
STUDENT HEALTH INSURANCE PLAN

2021-2022 Academic Year
Dependent Enrollment Form
 

Dependent coverage, if elected, begins and ends with the student’s coverage and must be purchased at the same time the student enrolls in the plan. 

The deadline to complete the Dependent Enrollment Form is July 1, 2021.


TO CONTINUE THE DEPENDENT ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

 (MM/DD/YYYY)