CHOATE ROSEMARY HALL

The following information is required if ELECTING a
Student Insurance Plan.
STUDENT INFORMATION M F
Are you a U.S. Citizen? Yes No
Student Name: ______________________________________
Date of Birth: _______________
__________________________________________________
HOME Street Address
__________________________________________________
City, State, Zip
__________________________________________________
Parents Signature
Please return this form with your check in the enclosed
envelope by October 15, 2012 to:
Consolidated Health Plans
2077 Roosevelt Avenue
Springfield, MA 01104
OR
You may enroll on-line at: www.chpstudent.com.
We accept both MasterCard and Visa.
For questions, please contact your servicing agent, Willis of CT,
LLC at 1-800-843-5404, ext. 45391.
Form EF-I5A18
19 20