CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2022-2023 POLICY PERIOD
SPRING ENROLLMENT FORM


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

Please note that your student ID must contain C + 8 digits (example: C70123456)

If you are an international student you have been automatically enrolled for coverage by Clark University and will not be required to complete the enrollment form.

 (MM/DD/YYYY)