UMASS-CHAN MEDICAL SCHOOL
STUDENT HEALTH INSURANCE PLAN
QUALIFYING EVENT ENROLLMENT FORM
DEPENDENT(S) COVERAGE ONLY
This form is for your dependent(s) ONLY. Students MUST contact the UMass Chan Medical School Bursar's Office at 508-856-6641 to enroll themselves in the coverage due to a qualifying life event.
A qualifying event is an event such as losing health coverage, getting married, having a baby, or entry into the USA. These changes can make you and/or your dependents eligible for a special enrollment period, allowing you to enroll in the student health insurance outside the open enrollment period.
Coverage may be purchased for your eligible dependents after the initial enrollment period only if one of the following qualifying events has occurred during the Policy Year: 1) birth; 2) adoption of a child; 3) marriage; 4) spouse’s/child’s loss of other creditable coverage; or 5) spouse’s/child’s entry into the United States. Please contact University Health Plans at 833-251-1122 for eligibility if you have a qualifying event not listed.
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 833-251-1122 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.
TO CONTINUE THE DEPENDENT ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:
