Simmons University

Undergraduate Student Health Insurance Plan 
Spring Enrollment Form 
January 1, 2019 - August 14, 2019


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

Please note if you just registered for classes you will have to wait a week to complete the form. Simmons University updates the authorization list for access to the forms once a week.

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