International Health Insurance OPT and J1 Dependent Enrollment Form

Enroll your dependents in health insurance available through SUNY. This form is for dependents of J-1 or Optional Practical Training (OPT) students.

If you did not yet read the informational insurance information, please do that before completing and submitting this form.

Print the Form

OPT/J1 Status Dependent Enrollment Form

Accessibility

* The University at Buffalo is committed to ensuring equal access to information that is presented online. As part of this commitment, university web content must be accessible to everyone, including individuals with physical, sensory, or cognitive impairments, with or without the use of assistive technology. If you encounter an accessibility issue when completing this form, please contact the health insurance office.

To Submit this Form, or Get Help

Student Health Insurance Office

Student Life

1 Capen
University at Buffalo
Buffalo, NY 14260-2100

Phone: (716) 645-3036