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Southern Illinois University Carbondale

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.

SIU Petition to Add.pdf

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.

  • Gallagher Student Health & Special Risk
    500 Victory Road, Quincy, MA 02171
  • Fax