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Student Health Insurance Waiver Form

Waiver Deadline Date: 09/17/10
The deadline date for submitting a waiver is September 17, 2010. All waiver submissions received after September 17, 2010 cannot be accepted. If you have any questions about the waiver submission process, please contact The Allen J. Flood Companies at: 800-734-9326.
1.	Name of School
2.	Location	Cannot be empty
3.	First Name of Student	Cannot be empty
4.	Middle Initial of Student	Cannot be empty
5.	Last Name of Student	Cannot be empty
6.	Permanent Residence
	Street Address	Cannot be empty
	Street Address (Suite/Apt Number)
	City	Cannot be empty
	State	Cannot be empty
	Country	Cannot be empty
	Zip	Cannot be empty
7.	Student's Date of Birth (mm/dd/yyyy)	Error In Entry
8.	Student's Gender	Cannot be empty
9.	Student I.D. Number	Cannot be empty
The following questions pertain to the student's own healthcare plan and not the plan offered by the College.
10.	Full Name of Health Insurance Company	Cannot be empty
11.	Group Number
12.	First Name of Policyholder	Cannot be empty
13.	Last Name of Policyholder	Cannot be empty
14.	Relationship of Policyholder to Student	Cannot be empty
16.	Relationship of person completing this form to the student	Please select
	Email Address:	Error in Entry
By clicking SUBMIT below, I affirm that I have health insurance coverage that meets the conditions described above. I certify that the information supplied is correct, and I am responsible for any incorrect information, whether intentional or otherwise.

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Student Health Insurance Waiver Form