University of Bridgeport
STUDENT HEALTH INSURANCE PLAN

Spring Enrollment Form for Dependents
2018-2019 Academic Year

Students who enroll in the UB Student Health Insurance Plan may also insure their Dependents. Eligible Dependents are your spouse (including a party to a civil union residing with the Insured) and children under age 26. 

After the 2018-2019 academic year, University of Bridgeport will no longer offer dependent coverage. 

If you would like to purchase the UB Student Health Insurance Plan for your dependents for the 2018-2019 academic year, please continue and complete the following online enrollment form.  The deadline to enroll in the annual plan is February 15, 2019.

NOTE: To enroll dependents in the UB Student Health Insurance Plan the student must be enrolled in the Student Health Insurance Plan. If you are not automatically enrolled in the Student Health Insurance Plan please complete your application before submitting an enrollment form for your dependents.

Part time undergraduate students and non resident graduate students may voluntarily enroll in the Student Health Plan under another form. 

Please enter your 7-digit UB Student ID and date of birth below.   If you do not know your UB Student ID, please contact the Bursar's Office at the University at (203)-576-4568. 

date of birth: (MM/DD/YYYY)
student ID: