LASELL COLLEGE
STUDENT HEALTH INSURANCE PLAN

Annual Waiver Form
2018-2019 Policy Period

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

Please note that your student ID must contain 9 digits (example: 000012345)

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

 

Student Health Plan

SHIP Premium Assistance for MassHealth Members

Optional Plans

Additional Information