Roger Williams University
STUDENT HEALTH INSURANCE PLAN

Qualifying Life Event Enrollment Form
2022-2023 Academic Year

If you have a qualifying life event outlined below, you may qualify for special enrollment rights to enroll in the student insurance plan outside of the initial enrollment period. 

Loss of Other Coverage:
  • Required Documentation: loss of coverage letter that includes your name and your last day of coverage
  • Deadline: 31 days from the last day of coverage in the prior plan
  • Effective Date of Coverage: the first day without coverage in the prior plan
Change in Residence (entry into the US or moving from coverage area)
  • Required Documentation:
    • If moving to the US: Identification page of Passport and page with U.S. entry date stamp
    • If moving within the US: travel documentation confirming a move to RI and documentation of active insurance coverage that does not provide coverage in RI. 
  • Deadline: 31 days from the entry into the US or move from the coverage area
  • Effective Date of Coverage: date of entry into the US or move out of other plan's service area. 

 (MM/DD/YYYY)