RUTGERS UNIVERSITY

2017-2018 Student Health Insurance Plan
SPRING DEPENDENT ENROLLMENT FORM

Students who have confirmed their own enrollment in the Rutgers University Student Health Insurance Plan (SHIP) may use this form to add eligible dependents to the plan. Eligible dependents are the spouse, domestic partner, or child(ren) of a Rutgers student who is also enrolled in the Student Health Insurance Plan.

Please note: Student status will be confirmed with Rutgers and enrollments made under the wrong category will be rejected and refunded. 

If you are an International student on an F OR J Rutgers sponsored visa please reach out to The Center for Global Services by calling (848) 932-7015 to check eligibility. Your dependent's enrollment will not be processed by completing this form. 

DEPENDENT ENROLLMENT COST FOR FULL TIME STUDENTS
Spouse/Domestic Partner - $1,191.00
Each Child - $1,191.00
Two or More Children - $2,382.00
All Dependents (Spouse/Domestic Partner and Two or More Children) - $3,573.00

DEPENDENT ENROLLMENT COST FOR PART TIME STUDENTS
Spouse/Domestic Partner - $2,896.00
Each Child - $2,896.00
Two or More Children - $5,792
All Dependents (Spouse/Domestic Partner and Two or More Children) - $8,688.00

 

DEADLINE: All Dependent enrollments must be submitted by February 2, 2018.

PLEASE NOTE - THIS COVERAGE IS ONLY EFFECTIVE 1/15/18 - 8/14/18

DEPENDENTS WILL NEED TO BE ENROLLED AGAIN FOR THE FALL 2018 SEMESTER


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)