CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2018-2019 POLICY PERIOD
ANNUAL ENROLLMENT FORM

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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: * Your Clark ID number begins with "C" followed by eight digits.
date of birth: * (MM/DD/YYYY)

 

Student Health Plan

SHIP Premium Assistance for MassHealth Members

Optional Plans

Additional Information