UMASS DARTMOUTH
STUDENT HEALTH INSURANCE PLAN
QUALIFYING EVENT ENROLLMENT FORM
STUDENT AND/OR DEPENDENT(S)

A qualifying event is an event such as involuntary loss of health coverage, getting married, having a baby, or initial entry into the U.S. 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 after the initial enrollment period only if one of the following qualifying events has occurred during the Policy Year: 1) involuntary loss of other health coverage; 2) birth of child; 3) adoption of a child; 4) marriage; or 5) initial entry into the United States. Please contact University Health Plans at 833-251-1124 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 833-251-1124 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 QUALIFYING ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW: