Brandeis University
STUDENT HEALTH INSURANCE PLAN

Spring 2023 Dependent Enrollment Form
2022-2023 Academic Year
 

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. 


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

 (MM/DD/YYYY)