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Family Add On Form

The family add on for winter 2018 has passed, the next available period is Fall 2018.

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 Student Benefit Plan 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.

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

2021 - 2022 Family Add-On Fees:
Health (one or more dependent) $165.00
Dental (one dependent) $165.00
Dental (two or more dependents)$330.00

Student Information

Sex
Date of Birth
Phone Number
Program Start Date

Service Members


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