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To be eligible for continuation Coverage, you must have been insured for at least 3 continuous months on the Purdue Student Health Insurance Plan, and you must submit premium within 30 days after your existing coverage terminates.
If you believe you are eligible for Continuation Coverage, please download the form below and follow the instructions to apply.
Sending the form in by fax to (855) 858-1964 is the preferred method. If you cannot fax the form in, you can email it to without filling in your payment information and one of our representatives will contact you to complete payment. Please be sure to include the telephone number where you can be reached.