Continuation Form - Student Health and Special Risk

USF

Marymount University

2023-2024 Marymount University Student Health Insurance Continuation Plan Enrollment Form

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Eligibility Requirement: All undergraduate students taking 12 or more credit hours, and graduate student taking 9 or more credit hours who have been continuously insured under the school's active student policy for at least one semester and who no longer meet the Eligibility requirements under the Policy are eligible to continue their coverage for a period of not more than three months (3) months under the school's policy in effect at the time of such continuation. If an Insured Person is still eligible for continuation at the beginning of the next Policy Year, the Insured must purchase coverage under the new policy as chosen by the school. Coverage under the new policy is subject to the rates and benefits selected by the school for that Policy Year.

You cannot re-enroll in the Continuation Plan after your Period of Coverage has expired. Enrollment in this Continuation Plan must be made within 15 days from the date that coverage terminates under the student's active Student Health Insurance Plan. You must be eligible to enroll in the plan and meet the enrollment deadline in order for your enrollment to be accepted by us. If it is discovered you do not meet the requirements your premium will be refunded.

Use the chart below to calculate the number of months you wish to continue coverage for yourself. Add the amounts in the Total Premium Column to confirm total payment.

Monthly Rate Premium X Number of Months (3 maximum) = Total

Student Only

Processing fee:

Total Payment Enclosed:

Notice to Student: By signing below, the student acknowledges the following: 1) He/She elects to continue coverage for the number of months as indicated above; 2) Continuation coverage can only be purchased for a maximum of three (3) continuous months and is non-renewable; and 3) If it is later determined that the eligibility or enrollment requirements have not been met, coverage will be terminated and the premium will be refunded.

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Questions? Contact Gallagher Student Health & Special Risk toll free 1-833-440-0570 or by going to www.gallagherstudent.com/Marymount and click on Help Center