WAIVERS WILL ONLY BE VALID IF SUBMITTED ONLINE TO STUDENT ASSURANCE SERVICES, INC.
ON OR BEFORE THE WAIVER DEADLINE of August 27, 2015.
Grinnell College Student Health Insurance Waiver Form
Full-Time Students are required to have a health insurance policy in force while attending Grinnell College.
I am waiving all rights to participate in the student health insurance program that is offered through Grinnell College
for the 2015-2016 academic year.
I attest that I have comparable coverage under a current insurance policy. If there is any change in coverage or
expiration of coverage, I agree to notify the College's Cashier Office and update the insurance information
I have on file.
I understand that I may enroll in the College insurance plan after the enrollment period deadline date only
if there is a qualifying event. In this event, I agree that the Plan Administrator must be notified and that the
enrollment and premium must be received no later than 31 days after the involuntary loss of coverage under
another insurance plan.
BY CHECKING THE BOXES AND ENTERING MY NAME BELOW I AM INDICATING MY INTENT
TO ELECTRONICALLY SIGN THIS WAIVER AND WARRANT THAT ALL OF THE INFORMATION
I HAVE PROVIDED IS TRUE, COMPLETE, AND ACCURATE.
Student's Name Electronic Signature
Please type your name in the spaces below to electronically sign your waiver:
(Parent or guardian if under 18 years of age)
Please re-type your name in the spaces below to confirm your electronic signature:
You will automatically be enrolled in and billed for the insurance plan unless you are
covered by comparable insurance, and submit this form by the deadline date.
We recommend that you review your student account statement periodically to insure that
proper credit has been issued to your account. Any dispute regarding insurance waivers
(waivers submitted after the deadline) must be addressed with the Cashier Office.
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