By submitting this information I agree that I am an active and eligible Research or Teaching Assistant or Fellowship recipient and wish to take advantage of the health insurance benefit. I understand that if I am terminated from my position I may be held responsible to repay the benefit amount and the full premium amount and will be responsible for all outstanding charges on my student account.

By clicking the submit button I agree to the terms outlined and will be automatically enrolled in the WPI student insurance.

This is an annual plan, the effective dates are August 12 – August 11th. You must re-enroll each year.

Please note: You must be registered for classes to complete this form.

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Term