Dependent Health Insurance Reimbursement Request
Enrolled graduate students in good standing are eligible for the reimbursement of out-of-pocket medical insurance premiums that have been paid and not covered by other means of up to $120* per month, per dependent (*effective for expenses accrued 9/1/2019 and beyond). If approved, the reimbursement will be paid as a miscellaneous payment through Payroll on the next available pay period following submission and approval.
  • Insurance Information

  • Start date
    End date
    mm/yyyy
  • Name
    Relationship to student
  • Name
    Relationship to student
  • Name
    Relationship to student
  • $ .
  • For example, a canceled check, paycheck stub, bank statement, itemized bill, or Caltech Bursar's statement reflecting at least one of the following: the carrier name, policy number, dates of coverage and individual(s) covered.