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FITCHBURG STATE UNIVERSITY
Student Health Insurance Program

Annual Waiver Form 
2025-2026 Academic Year


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.

Asterisk (*) denotes required field

 (MM/DD/YYYY)