MASSACHUSETTS MARITIME ACADEMY
STUDENT HEALTH INSURANCE PLAN
2018-19 ACADEMIC YEAR

 Annual 2018-19 Enrollment Form
(August 1, 2018 - July 31, 2019)

YES, I WANT TO ENROLL IN THE MASSACHUSETTS MARITIME ACADEMY STUDENT HEALTH INSURANCE PLAN


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
social security number: *
student ID:
date of birth: * (MM/DD/YYYY)