PLEASE READ: If you have been charged for, the Insurance do not complete this form.

By submitting this request, I agree that I am an active and eligible part time WPI Graduate Student. I elect to purchase the annual student health insurance plan. I understand that upon enrollment this plan may not be cancelled and or refunded for any reason. I also understand that I am responsible for the total premium at the current rate.

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

Please note: This form is to be completed if you are less than seven credits for the Fall semester.
You must be registered for classes to complete this form.

BY CLICKING, SUBMIT I AUTHORIZE WPI TO CHARGE MY STUDENT ACCOUNT THE HEALTH INSURANCE PREMIUM AND UNDERSTAND I AM RESPONSIBLE FOR THE TOTAL PREMIUM RATE. I ALSO UNDERSTAND THAT I WILL NOT BE ABLE TO REMOVE THIS CHARGE UPON ENROLLMENT.