UMASS-Dartmouth
STUDENT HEALTH INSURANCE PLAN

2018-2019 POLICY YEAR
DEPENDENT(S) COVERAGE ENROLLMENT FORM
JANUARY 1, 2019 - JULY 31, 2019


This form is for the dependents of newly registered spring students only.

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.

Coverage may be purchased for your eligible dependents after the initial enrollment period only if one of the following qualifying events has occurred during the Policy Year: 1) birth of a child; 2) adoption of a child; 3) marriage; 4) spouse’s/child’s loss of other creditable coverage; or 5) spouse’s/child’s entry into the United States. You must make the request by submitting a “Qualifying Event Enrollment Form” to University Health Plans, with supporting documentation showing that the qualifying event occurred within the last 60 days. Please reach out to University Health Plans for more information, 1-800-437-6448 or info@univhealthplans.com.

The spring 2019 policy period dependent enrollment deadline is March 1, 2019.


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)