Montclair State University
STUDENT HEALTH INSURANCE PLAN

Qualifying Event Enrollment Form
2025-2026 Academic Year

A qualifying event is an event like losing health coverage, getting married, having a baby, or entering the US. These changes can make you eligible for a special enrollment period, allowing you to enroll in the student health insurance outside the open enrollment period. 

You can use this form to enroll in the Montclair State University Student Health Insurance Plan. Please contact University Health Plans at 833-251-1705 if you have a qualifying event not listed below.

Loss of Other Coverage (losing health coverage through employer, parent's plan, or Medicaid)

Changes in Residence (entry into the US or moving out of existing coverage area)

All qualifying events require documentation to provide proof of your qualifying event. Documentation must be from the previous insurance company and clearly state the name and the date that coverage was lost. If you have questions about the documentation required, please contact University Health Plans at 833-251-1705 before you submit your enrollment form. 

Enrollment Deadline: The qualifying event enrollment form, payment, and required documentation must be received within 31 days from the qualifying event date.