UNIVERSITY OF MASSACHUSETTS - LOWELL
STUDENT HEALTH INSURANCE PLAN

Annual Dependent Enrollment Form
2022-2023 Academic Year

Dependent coverage, if elected, begins and ends with the student’s coverage and must be purchased at the same time the student enrolls in the plan.

The deadline to complete the 2022-2023 Annual Dependent Enrollment Form is October 14, 2022.

Your student ID# must be entered as an 8-digit number

Asterisk (*) denotes required field

STUDENT INFORMATION

 (MM/DD/YYYY)