FITCHBURG STATE UNIVERSITY
Student Health Insurance Program

2017-2018 Policy Year
Annual Term Enrollment Form


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

PLEASE NOTE: You must enter your Student ID number below, with the "@" symbol in front, in order to proceed. Entering your social security number will not allow you access to the enrollment form.

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