SUFFOLK UNIVERSITY

STUDENT HEALTH INSURANCE PLAN
2016-2017 ACADEMIC YEAR
WAIVER FORM

 

The deadline for submitting the Spring waiver form is February 10, 2017.

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

Asterisk (*) denotes required field

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