Rutgers Biomedical and Health Sciences

2017-2018 Student Health Insurance Plan
DEPENDENT ENROLLMENT FOR SPRING STUDENT ONLY

Students who have confirmed their own enrollment in the RBHS 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 RBHS student who is also enrolled in the SHIP. Students who are not currently enrolled in the SHIP may not purchase coverage for their dependents.

The Dependent Enrollment Deadline is February 25, 2018.


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)