Gordon College
STUDENT ACCIDENT & SICKNESS INSURANCE PROGRAM

ANNUAL 2017-18
Dependent Enrollment Form

THIS DEPENDENT FORM IS FOR STUDENTS ENROLLING IN THE SHIP FOR THE FIRST TIME STARTING WITH THIS 1718 POLICY.

YES, I want to purchase coverage for my dependents under the Gordon College Student Health Insurance Plan.


TO CONTINUE THE ENROLLMENT PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)