Indiana University
STUDENT HEALTH INSURANCE PLAN
Voluntary Domestic Qualifying Life Event Enrollment Form
2024-2025 Academic Year
Please read all information before submitting your form.
A qualifying life event is a change in your situation that makes you and/or your dependent(s) eligible to enroll in the insurance plan outside the initial enrollment period. This form can be used in the following situations.
Loss of Other Coverage:
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Required Documentation: letter that includes the insured's name and last day of ACA-compliant coverage
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Effective Date of Coverage: the first day without coverage in the prior plan
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Deadline: 30 days from the last day of coverage in the prior plan
Living Away From Plan's Service Area
- Required Documentation: Documentation from the student's insurance plan that confirms the location where the student lives while attending school is no longer in the plan's service area or documentation that the student has moved to a location outside the plan's service area mid-academic year.
- Effective Date of Coverage: The first day without coverage in the prior plan
- Deadline: 30 days from the date of the move or loss of other coverage
Birth or Adoption of Dependent:
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Required Documentation: official documentation of the birth or adoption
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Effective Date of Coverage: date of birth or adoption
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Deadline: 30 days from the date of birth or adoption
Marriage to Student:
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Required Documentation: copy of the marriage certificate
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Effective Date of Coverage: date of marriage
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Deadline: 30 days from the date of marriage
Indiana University email address must be submitted below
