Massachusetts College of Art and Design
Student Health Insurance Plan

2018-2019 Policy Year Waiver Form
August 1, 2018 - July 31, 2019 


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

first name:
last name:
date of birth: (MM/DD/YYYY)
student ID: (7 digits including leading zeros)