UMASS-BOSTON
STUDENT HEALTH INSURANCE PLAN

SPRING 2022-2023 POLICY PERIOD
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 Spring Dependent Enrollment Form is March 10, 2023.

Students who are currently enrolled in the University of Massachusetts – Boston Student Health Insurance Plan for the current policy year and did not submit a dependent enrollment form by the Fall deadline, cannot submit a dependent enrollment later in the same academic year unless the dependent has experienced a qualifying event (i.e., loss of other coverage, marriage, birth, entry into the United States).


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 (MM/DD/YYYY)