University of Bridgeport
STUDENT HEALTH INSURANCE PLAN

Part-Time Undergraduate Students and Non Resident Graduate Students

Spring Enrollment Form
2018-2019 Academic Year

If you would like to voluntarily enroll in the UB Student Health Insurance Plan, please continue and complete the following online enrollment form.  Once your enrollment is complete you must pay online by credit card or print the completed enrollment form and send payment to Unversity Health Plans. 

NOTE: All full-time undergraduate students, Physician Assistant students, and all students in campus housing are automatically enrolled in and billed by UB for the plan unless coverage has been specifically waived. This enrollment form should only be used by Part-Time Undergraduate Students and Non Resident Graduate Students who are not automatically enrolled.

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 UB at (203)-576-4568. 

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