UMASS-Lowell
STUDENT HEALTH INSURANCE PLAN

2017-2018 POLICY YEAR
DEPENDENT(S) COVERAGE 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.

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.

The deadline to complete the Dependent Enrollment Form is October 13, 2017.

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)