Application to opt in

Get ready to join the benefits plan

Opt in application form

Oops! Something went wrong while submitting the form. You can try again in a few hours or contact us.

Oops! We noticed that the student email, student ID, and date of birth you entered don't match our records. Please double-check your information and try submitting again.

Oops! This organization is not supported at the moment. Please contact us.

Unable to save the attachment. Please verify your selected file size and format and try to submit again.

You are not eligible to opt-in at this time. The opt-in policy requires you to opt in only during the change of coverage period.

Student information

First name

Please enter your first name.

Last name

Please enter your last name.

Date of birth

Select or type the date. Date format should be MM-DD-YYYY. Example is 05-18-1998.

Please enter your date of birth.

Student ID

This will help us validate your enrollment status.

Please include your student ID.

Please enter a valid email address.

About your previous coverage

Last date of coverage

Select or type the date. Date format should be MM-DD-YYYY. Example is 05-18-1998.

Please enter your last day of coverage.

Proof of coverage

Max. file size 10 MB. Valid file types: PDF, PNG, JPEG, and JPG.

Please select a file.

Upload File

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Student plan coverage

What would you like to opt in to?

Please note that opting in to health benefits includes prescription drugs, extended healthcare, vision, virtual care, and out of country coverage.

Please select one.

HealthDentalBoth

Please accept the terms of use.

You can enroll in the plan(s) by the posted deadline or within 30 days of losing your previous coverage. By enrolling into the plan(s), you accept that you must pay the appropriate coverage fee by the set deadline. If you are re-enrolling under the event that you have lost additional coverage, you understand that you are required to provide the appropriate documentation providing proof of loss of alternate coverage alongside your re-enrollment application. StudyWell Benefits reserves the right to request additional documentation if required to confirm your eligibility status.

An envelope showing a white checkmark on a circular green container. The form submission was successful.

We received your application!

You will receive a confirmation email shortly with more information about the next steps.

Before you start

Before filling out the form, we recommend you have in hand the following information and documents:

Your student ID

Proof that the coverage used to opt-out of the health and dental plans has lapsed within the past 30 days. This may include a termination from the insurer.

What happens after I submit the application form?

After submitting the form, you will receive a confirmation email. The StudyWell team will contact you to complete the verification process and provide details about the final steps.

Start receiving benefits

Are you eligible to opt back in?