RUTGERS UNIVERSITY
CONTINUATION OF ENROLLMENT FORM FOR FULL TIME STUDENTS
AND THEIR DEPENDENTS
Eligibility: All Insured Persons who have been continuously insured under the school's regular student Policy for at least
3 consecutive months and who no longer meet the Eligibility requirements under that Policy is eligible to continue their
coverage for a period of not more than 90 days 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 2016-519-2 is subject to the rates
and benefits selected by the school for that policy year.
Student’s Name____________________________Date of Birth:____________Rutgers RUID#:____________________
Address:________________________________________City:___________________State:_____Zip:______________
Email:__________________________________________
If you are enrolling Dependents, list Dependents to be insured below.
Dependent coverage is available ONLY if the student is also insured under the Plan.
Last Name
First Name
MI
Date of Birth
Gender
Spouse:
Child:
Child:
Please check the period of coverage desired:
Period of Coverage
Student Only
Spouse
One Child
Two or More
Spouse and Two
Children
or More
Children
1 Month – 8/15/16 – 9/14/16
______ $163.59
______ $163.59
______ $163.59
______ $327.18
______
$490.77
2 Months – 8/15/16 – 10/14/16
______ $327.18
______ $327.18
______ $327.18
______ $654.36
______
$981.54
3 Months – 8/15/16 – 11/14/16
______ $490.77
______ $490.77
______ $490.77
______ $981.54
______
$1,472.31
*PLEASE NOTE: The Continuation Privilege will allow you to purchase up to a maximum of 3 consecutive months, but
not longer than the current plan year. Include full payment based on the coverage selected and the number of months chosen.
Payment will not be accepted on a month-to-month basis. Incorrect payment amounts will be returned and no coverage
will be in effect.
Make your check or money order for the total applicable premium listed above payable to University Health Plans.
Please return this form along with payment to:
University Health Plans, Inc.
One Batterymarch Park
Quincy, MA 02169
NOTICE TO STUDENT: Coverage is effective immediately following the expiration of the regular student plan and
must be purchased within 31 days after the expiration date of your student coverage. If premium is not received within 31
days, the premium will be refunded. By signing, the student acknowledges the following: 1) He/She has carefully read the
brochure and elects to enroll as indicated on this enrollment card; 2) Rates are not pro-rated other than as listed on this
enrollment card; 3) He/She meets the eligibility requirements for this coverage as described in the brochure; and 4) If it is
later determined that the student is not eligible, the premium will be refunded. Premium will not be refunded except for
ineligibility or entrance into the armed forces. Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
STUDENT'S SIGNATURE:_______________________________________________ DATE:___________________