Georgia State University

Qualifying Life Event Request

NATURE OF YOUR QUALIFYING LIFE EVENT:
If you experience a Qualifying Life Event (QLE) (e.g. loss of health insurance coverage, no longer eligible on your
parent’s health insurance, marriage, etc.) during the plan year August 1, 2022 - July 31, 2023 you can enroll in the
Georgia State University health insurance for the remainder of the current coverage period. Please complete this form
and sign and date it.

Reason for Qualifying Event:

Other (please detail)
Loss of coverage under another plan
Marital Status
Adoption of a Child/Birth of a Child
Guardianship Appointment
International Students: Arrival of Spouse/Dependents in Country
Date of Qualifying Life Event:

PRIMARY INSURED INFORMATION:

Gender: M
F

Name:
(Last name, first name)

Student ID #:
(Required)

Birth Date:
(mm/dd/yyyy)

Address:
(Street, City, State, ZIP)

Student Phone #: Email Address:

(Home phone or cell phone)

21COL4217-201-1
ENROLLMENT & PAYMENT INSTRUCTIONS:
A QLE is required for primary insureds and dependents to be eligible to enroll in the school health insurance plan
at a time outside of the enrollment period. Enrollment in the plan must occur within 30 days of the QLE. Premiums
are not pro-rated.

Make check or money order payable to UnitedHealthcare StudentResources. Mail this completed form, your school
injury and sickness insurance enrollment form, required supporting documentation, along with premium payment
to: UnitedHealthcare StudentResources; PO Box 809026; Dallas, TX 75380-9026.

To pay with a credit card: If you want to pay for your coverage with or eCheck, email this completed form, your school injury and
sickness insurance enrollment form, required supporting documentation, to [email protected] or fax it
to 469-229-5612. Make sure your email address is correct as we will enter your coverage request into our system and send you
an email message with instructions for making your premium payment online with a credit card or eCheck.

Student Signature: Date:

FOR MORE INFORMATION: Call customer service at 1-866-403-8267.

FOR ADMINISTRATIVE USE ONLY:

Date:
Effective Enrollment Period Dates:
Approved By:
Premium Amount:

21COL4217-201-1
 Processor Date Stamp Received Here

UNITEDHEALTHCARE INSURANCE COMPANY

QUALIFYING LIFE EVENT ENROLLMENT FORM FOR STUDENTS AND THEIR DEPENDENTS

GEORGIA STATE UNIVERSITY 2022-201-1

PRIMARY INSURED COMPLETE INFORMATION BELOW FOR STUDENT.

LAST (FAMILY) NAME: FIRST (GIVEN) NAME: MIDDLE INITIAL:

GENDER: DATE OF BIRTH: SCHOOL ID #:

 MALE  FEMALE (MONTH/DAY/YEAR)

PERMANENT U.S. ADDRESS: (HOUSE/BUILDING # AND STREET NAME)

CITY: STATE: ZIP CODE:

TELEPHONE #: EMAIL ADDRESS:

DEPENDENT INFORMATION
Complete information below for dependents to be insured. Dependent coverage is only available for students insured under
the Plan (Please include a blank sheet for additional dependents).
SPOUSE: GENDER: DATE OF BIRTH:
 MALE  FEMALE (MONTH/DAY/YEAR)
First (Given) Name: Middle Initial: Last (Family) Name:

CHILD: GENDER: DATE OF BIRTH:

 MALE  FEMALE (MONTH/DAY/YEAR)
First (Given) Name: Middle Initial: Last (Family) Name:

CHILD: GENDER: DATE OF BIRTH:

 MALE  FEMALE (MONTH/DAY/YEAR)
First (Given) Name: Middle Initial: Last (Family) Name:

CHILD: GENDER: DATE OF BIRTH:

 MALE  FEMALE (MONTH/DAY/YEAR)
First (Given) Name: Middle Initial: Last (Family) Name:

CHILD: GENDER: DATE OF BIRTH:

 MALE  FEMALE (MONTH/DAY/YEAR)
First (Given) Name: Middle Initial: Last (Family) Name:

NOTICE TO STUDENT: Coverage will be effective the date the correct premium is received by the Company or a
representative of the Company or the effective date of the coverage period, whichever is later, unless otherwise stated in the
Master Policy. By signing, the student acknowledges the following: 1) The student has carefully read the Certificate of Coverage
and elects to enroll as indicated on this enrollment form; 2) Rates are not pro-rated other than as listed on this enrollment card;
3) The student meets the eligibility requirements for this coverage as described in the Certificate of Coverage; 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.

NOTICE: Any person who knowingly and with intent to injure, defraud, or deceive any insurer, files a statement of claim
containing any false, incomplete, or misleading information may be subject to criminal and/or civil penalties.

Student’s Signature: Date:

EF-2019 1 of 2
 GEORGIA STATE UNIVERSITY 2022-201-1

Campus/School Attending: _______________________________________________________________________________

Please print name of University. Must be completed in order for application to be processed.

☐ I elect to purchase Injury and Sickness insurance coverage under the University’s student insurance plan.
Below are the choices I have made.

PLEASE CHECK ALL APPROPRIATE BOXES.

INSURED CATEGORY: ☐ Graduate ☐ MBA Global

ID Codes Monthly (MX)

1 Student ☐ $ 223.00
2 Spouse ☐ $ 245.00
3 One Child ☐ $ 245.00
4 Two or more Children ☐ $ 490.00
5 Spouse and 2 or more Children ☐ $ 735.00

TO CALCULATE YOUR RATE:

Rate x# of months eligible = amount due
Example: $223.00 x 3 months = $669.00
Please multiply the rate and number of days and/or months to get your total premium.
Student $223.00 x _____ months = $ ________

Spouse $245.00 x _____ months = $ ________

One Child $245.00 x _____ months = $ ________

Two or More Children $490.00 x _____ months = $ _________

Spouse and 2 or More Children $735.00 x _____ months = $ _________

Total $ _________________

** Please note: premiums are cumulative (Ex. Student + Spouse = Total premium due).

Requested Effective Date: _______ / ______ / _____ Termination Date: 7/31/2023

Payment Instructions: Make check or money order payable to UnitedHealthcare StudentResources in US dollars. Mail
this enrollment form along with premium payment to:

UnitedHealthcare StudentResources
PO Box 809026
Dallas, TX 75380-9026.

Your cancelled check or credit card billing is your only receipt and notification of coverage. The student is responsible for
timely premium payments whether or not a premium notice is received.

HOW TO ENROLL OR PAY ONLINE

Online Enrollment:
If your school allows online enrollment and you would like to purchase your coverage using a credit card or eCheck, please
visit www.uhcsr.com/gsu. You can search for your school, choose your plan, and click on EXPLORE POLICY to review
plan documents. To purchase coverage, click on ENROLL NOW and follow the on screen prompts to complete your
enrollment.

EF-2019 2 of 2
 NON-DISCRIMINATION NOTICE

UnitedHealthcare StudentResources does not treat members differently because of sex, age, race, color, disability or
national origin.

If you think you were treated unfairly because of your sex, age, race, color, disability or national origin, you can send a
complaint to:

Civil Rights Coordinator

United HealthCare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UTAH 84130
[email protected]

You must send the written complaint within 60 days of when you found out about it. A decision will be sent to you within 30
days. If you disagree with the decision, you have 15 days to ask us to look at it again.

If you need help with your complaint, please call the toll-free member phone number listed on your health plan ID card,
Monday through Friday, 8 a.m. to 8 p.m. ET.

You can also file a complaint with the U.S. Dept. of Health and Human Services.

Online https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Phone: Toll-free 1-800-368-1019, 800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services. 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201

We also provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you
can ask for free language services such as speaking with an interpreter. To ask for help, please call the toll-free member
phone number listed on your health plan ID card, Monday through Friday, 8 a.m. to 8 p.m. ET.

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