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Family Add On Form

Family Add On


Coverage provided through the Student Health and Dental plan can be extended to a spouse and/or dependent(s). To add eligible dependent(s) complete the sections below and submit this form. You will then be contacted by the VSAOC Office, via an email notification, of any required supporting documents and fees. All supporting document(s) and fees must be received by the applicable deadline in order for the family add on process to be completed.

IMPORTANT: These fees are in addition to the student health and dental fee.

2019 - 2020 Family Add-On Fees:
Health (one or more dependent) $​​1​26.38
Dental (one dependent) $​​220.00
Dental (two or more dependents) $​290.00

Please read and agree to the Terms & Conditions prior to submitting your online Family Add On form.

Student Information

Gender
Date of Birth
Phone Number
Program Start Date

Service Members


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