BECKER COLLEGE
STUDENT HEALTH INSURANCE PLAN

ACCELERATED STUDENTS
2017-2018 POLICY YEAR

ENROLLMENT FORM

This enrollment form should be used by accelerated students who are being automatically charged for the Student Health Insurance Plan and want to expedite the processing of their data in the insurance plan's system.

This enrollment form should not be used by any part-time student who wants to voluntarily purchase the Student Health Insurance Plan. A link to the Part-Time Student Enrollment Form can be found on the left side of this page.

The coverage period for this plan is August 9, 2017, through August 8, 2018.
The enrollment deadline is midnight on November 17, 2017.

 


Complete the following fields to continue to the Accelerated Student Enrollment Form:

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
student ID: * (7 digits including leading zeros)
date of birth: * (MM/DD/YYYY)