UNIVERSITY OF MASSACHUSETTS - LOWELL
STUDENT HEALTH INSURANCE PLAN

Annual Dependent Enrollment Form
2023-2024 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 Annual 2023-2024 Dependent Enrollment Form is October 13, 2023.

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