FITCHBURG STATE UNIVERSITY
Student Health Insurance Program

2018-2019 Policy Year
Annual Term Waiver Form


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

PLEASE NOTE: You must enter your Student ID number below, with the "@" symbol in front, in order to proceed (Example: @XXXXXXXX). Entering your social security number will not allow you access to the waiver form.

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