Continuation Form - Gallagher Student Health and Special Risk

Dear Student,

Thank you for your interest in the 2022-2023 University of North Florida Continuation Plan for students previously insured in the Student Health Insurance Plan. This plan is underwritten by UnitedHealthcare Insurance Company and is serviced by Gallagher Student Health & Special Risk. UnitedHealthcare Student Resources is the Claims Administrator.

There are a few key provisions we would like to bring to your attention:

Please review the eligibility section thoroughly to ensure you are eligible to enroll.
The enrollment form must be received within 15 days of your termination date under the UNF Student Health Insurance Plan. Your coverage effective date will be retroactive to the day following your termination date under the Student Health Insurance Plan. If the deadline is not met, you will not be able to enroll in the Continuation Plan.
Students are allowed to purchase up to three (3) months of coverage and must select the term of coverage at the time of their initial enrollment. However, once the period of coverage the student elects terminates, they will not be eligible to re-enroll for another term of coverage.
The Continuation Plan duplicates the coverage of your current Student Health Insurance Plan.
Students will receive a new identification card. The Continuation Plan includes health care providers affiliated with the UnitedHealthcare Choice Plus PPO Preferred Provider Network. You can locate Choice Plus PPO providers at www.gallagherstudent.com/UNF under “Find a Doctor”.
You must be eligible to enroll in the Continuation Plan and meet the enrollment deadline in order for your application to be accepted by us. If it is discovered you do not meet the requirements, your premium will be refunded.
This Continuation Plan does not require Pre-Certification to access Benefits.
Enrolling in the Continuation Plan does not guarantee additional benefits for a covered Injury or Sickness.

Once Gallagher Student Health & Special Risk receives your completed enrollment form and applicable premium, we will process the application and send your information to the Claims Administrator.

If you have any questions, please contact us at 1-877-535-2482 or by clicking the ‘Help Center’ link on our website.

Sincerely,

Client Services

Form Name

University of North Florida

The UnitedHealthCare Insurance Company

2022-2023 Continuation Plan Enrollment Form - International Students

* indicates field is required

First Name*

Last Name*

Student ID*

Email Address*

Street*

City*

State*

ZipCode*

Telephone*

Date of Birth*

Gender*

Eligibility Requirement: All registered international students with J-1 or F-1 visas are automatically enrolled on a hard waive basis who no longer meet the eligibility requirements for the International Plan, but have been continuously insured under the school's student policy for at least one semester are eligible to continue their coverage for a period of not more than three (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.

Calculate Your Premium

You must decide at the time of enrollment the period of coverage to purchase. 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 Injury and Sickness 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 and your dependents. Add the amounts in the Total Premium Column to confirm total payment.

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

Student Only

Spouse

One Child

Two or More Children

Spouse & Two or More Children

Processing fee:

Total Payment Enclosed:

Continuation coverage for dependents must be purchased at the same time of student enrollment. Dependents can be enrolled only if, (a) they were previously enrolled under the active Student Injury and Sickness Insurance Plan, (b) the student enrolls in the Continuation Plan and (c) they are enrolled for the same period of coverage as the enrolled student. List Dependents to be insured below

Students enrolling dependents for the first time are required to provide documentation of dependent status.

DEPENDENT NAME

RELATIONSHIP

DATE OF BIRTH(mm/dd/yyyy)

Upload Documents The acceptable file types are pdf, jpg, gif, png, jpeg

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.

I acknowledge*