ENDICOTT COLLEGE
STUDENT HEALTH INSURANCE PLAN

Undergraduate Annual Enrollment Form
2021-2022 Policy Period

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

Please note that your student ID must contain 6 digits (example: 001234)

Asterisk (*) denotes required field

STUDENT INFORMATION

 (MM/DD/YYYY)