Petition to Add Form
Students who initially waived the student insurance plan can petition to add coverage if they experience a qualifying event. Qualifying events include:
- Reaching the age limit of another health insurance plan
- Loss of health insurance through a marriage or divorce
- Involuntary loss of coverage from another health insurance plan
A qualifying event does not include a student who is seeking enrollment to gain access to a benefit that was exhausted under their current private insurance plan. If you have experienced a qualifying event and would like to enroll in your college/ university's student medical plan, complete a Petition to Add Form.
All documents are in .PDF format. In order to read and print the PTA form, you will need to have Adobe Reader downloaded and installed on your computer. You may click on the image below to download Adobe Reader.
Protect what's yours.
Considering purchasing a high-deductible insurance plan instead of your school's sponsored plan?
- Gallagher Student Health & Special Risk
500 Victory Road, Quincy, MA 02171
- Toll Free