Health Insurance Waiver/Enrollment Form (For Business Office)
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Health Insurance Waiver/Enrollment Form (For Business Office)
DUE AUGUST 9, 2013
All students are required to be enrolled in either a private health insurance plan or to carry health coverage through Washington & Jefferson College.
PLEASE NOTE: If you are covered by a private health insurance plan, the College health insurance premium will be assessed to your bill until you file this waiver with the Business Office.
1.
Student Full Name
*
2.
W&J ID number
*
3.
Student's Email
*
4.
PLEASE CHECK ONLY ONE:
*
I understand that I may waive W&J College's health insurance plan only if I have other medical coverage, and I hereby represent that I am covered through: (Insert company information below)
I wish to be enrolled in the private health insurance offered through W&J College. I understand that an insurance premium will be assessed to my fall tuition bill. Coverage extends from September 1, 2013 to August 31, 2014.
5.
If you selected that you have other medical coverage, please enter that company's information below.
(To waive W&J College's health insurance plan, the company information must be listed below.)
Company Name
Group Number
Agreement Number
Click "Done" to submit to Business Office