UNIVERSITY OF DELAWARE
STUDENT HEALTH INSURANCE PLAN
2024-2025 POLICY YEAR

DEPENDENT ENROLLMENT FORM

This Dependent Enrollment Form is used by students enrolled in the Student Health Insurance Plan (UD Plan) to add coverage for their eligible dependents. Enrolled dependents will be given the same effective date applied to the student’s UD Plan. Dependent enrollment will NOT be processed until the student has also enrolled.

Eligbility: Eligible dependents for this plan include a legally married spouse, civil union partner, and children under the age of 26. Domestic Partners are not eligible for the plan.

Important Notice: Proof of your dependent(s) eligibility through submission of marriage certificate, civil union certificate or birth certificate may be requested.

Enrollment Deadline: Voluntary Dependent Enrollment Forms must be submitted with full payment by  September 15, 2024. Enrollment will be made effective as of 8/15/2024.

If you have read the information above and wish to continue to the Dependent Enrollment Form, complete the fields below.