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Family Add On

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

Family Add On


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Some things to read before continuing:

- Only complete the form if your family has lost their alternative coverage in the last 30 days. Proof will be required at this time.

- Please contact the Benefit Plan Office should you have any questions, prior to submitting the form.

 

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 SU Health and Dental 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.

Student Information

Gender
Date of Birth
Phone Number
Program Start Date

Service Members


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