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Student Health Insurance Waiver Form


Waiver Deadline Date: 08/09/16

Graduate students and students taking less than 12 credit hours are not required to complete the waiver form. International students CANNOT submit a waiver. The deadline to submit the waiver is 08/09/2016 @11:59 p.m. No waiver will be accepted after 08/09/2016

1. Name of School
2. First Name of Student
3. Middle Initial of Student
4. Last Name of Student
5. Permanent Residence  
  Street Address
  Street Address (Suite/Apt Number)
  City
  State
  Country
  Zip
6. Student's Date of Birth
(mm/dd/yyyy)
   
7. Student's Gender
8. Student I.D. Number
Your Student ID # is the same as your Campus Wide ID (CWID)
9. Full Name of Health Insurance Company
10. Does this health insurance company have a United States based office for submitting claims?  
11. Type of Plan
12. Member ID# of Student
13. Policy Effective Date
14. Group Number
15. First Name of Policyholder
16. Last Name of Policyholder
17. Relationship of Policyholder to Student
18. Date of Birth of Policyholder
(mm/dd/yyyy)
   
19. Address For Submitting Medical Claims To Your Insurance Company
(If you have a Cross Blue Shield (BCBS) plan and if your card asks providers to send claims to the local BCBS plan, please enter "Send to local BCBS plan" in this space)
20. Member Services Phone Number
21. Does Your Plan Include Prescription Drug Coverage?  
22. What is the name of the person completing this waiver form?
23. Relationship of person completing this form to the student
  Email Address:
By clicking the "Submit" button below, I certify that the information provided above is truthful and accurate to the best of my knowledge. Marist College reserves the right to request a copy of the policy and identification card as evidence of other insurance. If requested, please submit these items to the College promptly.
 

 
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