Premium Adjustment Request Form

Name(Required)

First (& middle name, if appicable) Last

BU ID Number(Required)

BU Email(Required)

Program of Study(Required)

Citizenship Status(Required)

U.S. Domestic

International

• I am requesting to terminate my 2026-2027 plan year Boston University Student Health Insurance Plan (SHIP) coverage as of December 31, 2026, at 11:59 p.m., and have my Fall 2026 Student Health Insurance charge reduced to the corresponding Fall-only rate.

• I understand that if I have enrolled my dependents in the Boston University Student Health Insurance Plan (SHIP) their coverage will terminate at the same time and their premiums will be adjusted to the corresponding dependent Fall-only rate..

• I understand that between January 1, 2027, and August 14, 2027, I will be responsible for all Health Insurance expenses incurred by me and neither Boston University nor its Student Health Insurance Plan (SHIP) will be responsible.

• I understand that if my anticipated Spring 2027 term registration status changes and I no longer qualify for the premium adjustment, the premium adjustment will be reversed and I will be responsible for the full 2026-2027 annual premium.

Fall 2026 status (please select one option below):(Required)

Full-time student with 12 credits or more

Certified full-time student enrolled in between 0 and 11.5 credits

Part-time student enrolled in at least 75% of a full-time course load (for most programs, between 9-11.5 credits)

Part-time student enrolled below 75% of a full-time course load (for most programs, fewer than 9 credits)

Spring 2027 status. The following conditions may qualify a student to change to the Fall Only coverage period. Please select those options that apply to you Spring 2027:

I will be graduating in December 2026

I will be on leave of absence for Spring 2027

I will not be registered through BU for Spring 2027

I am a domestic student and for Spring 2027 will be registered as a part-time student below 75% of a full-time course load.

I will be an online-only student for Spring 2027

Request for Fall-Only SHIP