MASSACHUSETTS MARITIME ACADEMY
STUDENT HEALTH INSURANCE PLAN
2019-20 POLICY YEAR WAIVER FORM

Annual Waiver Form
(August 1, 2019 - July 31, 2020)


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

Asterisk (*) denotes required field

STUDENT INFORMATION

 
 (MM/DD/YYYY)