Student Health Insurance Plan Enrollment Request Form

(Processing Time 3 Business Days)

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First Name

Middle Name

Last Name

Academy Student ID

Please double-check your Student ID to ensure it is correct and ensure it begins with a zero (0), like this: 05555555

Email Address

Telephone

Date of Birth

Please enter in this format: MM/DD/YYYY

Please enter your U.S. address below:

Street Address

Street Address 2 (Apartment/Room/Unit Number)

City

State

Zip Code

I request to enroll in the Academy's Student Health Insurance Plan for the following semester:

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