University of Bridgeport
STUDENT HEALTH INSURANCE PLAN

New Spring Student Voluntary Enrollment Form
2022-2023 Academic Year

Students in the School for Professional Studies, part-time students (enrolled in 7 or more credits but not living on campus) and graduate students (enrolled in 6 or more credits but not living in campus housing) are not automatically enrolled but may participate in the Student Health Insurance Plan voluntarily. Distance Learning students are not eligible to participate in the Plan. Home study, correspondence, Internet, and television (TV) courses do not fulfill the Eligibility requirements.

If you would like to enroll voluntarily 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. 

Your eligibility will be verified before your enrollment is processed. You must maintain your eligibility for the first 31 days of classes. 

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

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. 

 (MM/DD/YYYY)