•  SHIP ENROLLMENT FOR DEPENDENT(S) 2026-2027

  • For questions or assistance filling out this form, contact the ASA Student Health Insurance office at (631) 632-6054 or email us at studenthealthinsurance@stonybrook.edu

  • Student Information

  • Student Date of Birth*
     - -
  • Student Gender*
  • Format: (000) 000-0000.

  • Program/Enrollment Information

  • Check boxes that apply to STUDENT enrollment already completed:*

  • Dependent Information

  • Spouse/Partner Date of Birth
     - -
  • Spouse/Partner Gender
  • Child 1 Date of Birth
     - -
  • Child 1 Gender
  • Child 2 Date of Birth
     - -
  • Child 2 Gender
  • Child 3 Date of Birth
     - -
  • Child 3 Gender

  • Coverage Selection and Amounts

  • Coverage Category (Fall 2026)
  • Coverage Category (Spring/Summer 2027)
  • Should be Empty: