Continuation Form - Gallagher Student Health and Special Risk

FormName

2023-2024 University of the Pacific Student Health Insurance Continuation Plan Enrollment Form

Eligibility: Only students who graduate, withdraw, or drop out AFTER the first 45 days from the start of the term, can purchase continuation coverage.

First Name*

Last Name*

Student ID*

Email Address*

Street*

City*

State*

ZipCode*

Telephone*

Date of Birth*

Gender*

STUDENT ENROLLMENT

Student Type*

Dates of Coverage*

Amount

Prosessing Fee

Total

Please Note: Enrollment Forms will not be accepted after these deadlines

Notice to Students:
Coverage will be effective the first date of the Coverage Period when the correct premium is received by Gallagher Student Health & Special Risk by the Enrollment Deadline; Enrollment Forms will not be accepted after the Enrollment Deadline has passed. It is the student’s responsibility for timely renewal payment. By signing below, the student acknowledges the following: 1) He/She has carefully read the brochure and elects to enroll as indicated on this enrollment form. 2) Rates are not prorated other than as listed on this enrollment form. 3) Enrolled Student meets the eligibility requirements for this coverage as described in the brochure. 4) If it is later determined that the student is not eligible, the premium will be refunded. 5) Other than for eligibility reasons, the premium is not refundable.

I acknowledge*