Worcester Polytechnic Institute
STUDENT HEALTH INSURANCE PLAN

Dependent Qualifying Event Enrollment Form
2025-2026 Academic Year

A qualifying event is a change in situation like losing health insurance coverage, getting married, having a baby, or moving. These changes can make your dependents eligible for a special enrollment period, allowing you to enroll them in the student health insurance plan outside the open enrollment period. 

You can use this form to enroll your eligible dependents in the WPI student health insurance plan. Please contact University Health Plans at 877-514-2091 for eligibility if your dependent has a qualifying event not listed below.

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

Changes in Household (getting married or divorced, having a baby or adopting a child, or death in the family)

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. If you have questions about the documentation required, please contact University Health Plans at 877-514-2091 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 WPI student ID# is 9 digits.