SHIP ENROLLMENT FOR STUDENTS 2026-2027

SHIP ENROLLMENT FOR STUDENTS 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 Name

First NameLast Name
SBU ID #
9-digit number on your Stony Brook University ID card
Student Date of Birth

MonthDayYear
Student Gender

Other
Street Address
Town/City
State
Zip
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Program/Enrollment Information
Check boxes that apply to STUDENT enrollment already completed:

Other Graduate Program
full time; # of semester credits
Semester(s) of coverage - Select one or both to be billed to your student account
Should be Empty:

Student Information