SUFFOLK UNIVERSITY

2016-2017 Student Health Insurance Plan
DEPENDENT ENROLLMENT FORM

Students who have confirmed their own enrollment in the Suffolk University Student Health Insurance Plan (SSHIP) may use this form to add eligible dependents to the plan. Eligible dependents are the spouse or child(ren) of a Suffolk student who is also enrolled in the SSHIP. Students who are not currently enrolled in the SSHIP may not purchase coverage for their dependents.

The Dependent Enrollment Deadline is February 10, 2017.


To continue the dependent enrollment process, please fill out the required fields below:

Asterisk (*) denotes required field

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