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UNIVERSITY OF MASSACHUSETTS - LOWELL
STUDENT HEALTH INSURANCE PLAN

Annual Waiver Appeal Form
2026-2027 Academic Year

 

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

THE WAIVER APPEAL DEADLINE IS 5:00 PM EST October 23, 2026

Asterisk (*) denotes required field

STUDENT INFORMATION

 
 (MM/DD/YYYY)