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CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2023-2024 Policy Year
Qualifying Life Event Enrollment


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 Clark University Student Health Insurance Plan. Please contact University Health Plans at 833-251-1733 if you have a qualifying event not listed below.

Loss of Other Coverage (losing health coverage through employer, parent's plan, or Medicaid - prior coverage must be a US Health Plan that is fully compliant with the US Affordable Care Act (ACA)

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 within 60 days of the qualifying life event. If you have questions about the documentation required, please contact University Health Plans at 833-251-1733 before you submit your enrollment form. 

Enrollment Deadline: The qualifying event enrollment form, payment, and required documentation must be received within 60 days from the qualifying event date. 

Please note, your student ID# begins with a C followed by 8 digits (example: C70123456)

 (MM/DD/YYYY)