Stevens Institute of Technology

Student Insurance Enrollment Form
2017-2018 Academic Year
 Spring Registered Graduate Students Only


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

You must provide your 8 character Campus Wide ID (CWID) NOT your Social Security Number. If you do not know your CWID, you can retrieve it with your myStevens account by logging in at http://www.stevens.edu/mystevens and then clicking on the “SHOW MY CWID” link on the upper left hand side of the page. Please ensure the accuracy of the CWID you provide or your waiver application will not be accepted.

****Attention Undergraduates****

If you enrolled your health insurance through the Graduate Student link, the health insurance charge will NOT be added to your Stevens account. If you are having difficulty logging into the Graduate link, please contact the Student Service Center at 201-216-5555. Health Insurance cannot be enrolled until it is charged to your Stevens account.

International Students: If you do not have a social security number to provide in this enrollment form, please use a leading "0" plus your campus wide ID#.  

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number: *
Campus Wide ID (CWID): *
date of birth: * (MM/DD/YYYY)