BECKER COLLEGE
STUDENT HEALTH INSURANCE PLAN

PART-TIME  STUDENTS
2018-2019 POLICY YEAR

ANNUAL ENROLLMENT FORM

This enrollment form should be used by part-time students who wish to volunatarily enroll in the Student Health Insurance Plan.

The coverage period for this plan is August 9, 2018, through August 8, 2019.

The enrollment deadline is midnight on September 7, 2018.


Complete the following fields to continue to the Part-Time 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)