Continuation Form - Gallagher Student Health and Special Risk

USF GATARA

University of South Florida

The UnitedHealthCare Insurance Company

2022-2023 Student Health Insurance Continuation Plan Enrollment Form

* indicates field is required

First Name*

Last Name*

Student ID*

Email Address*

Street*

City*

State*

ZipCode*

Telephone*

Date of Birth*

Gender*

Eligibility Requirement: All Graduate/Teaching/Research Assistants and Post-Doctoral Scholars who no longer meet the eligibility requirements for the GA/TA/RA 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*