MASSACHUSETTS MARITIME ACADEMY
STUDENT HEALTH INSURANCE PLAN
2019-20 POLICY YEAR ENROLLMENT FORM

 Annual Enrollment Form
(August 1, 2019 - July 31, 2020)

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

 
 (MM/DD/YYYY)