WAIVERS WILL ONLY BE VALID IF SUBMITTED ONLINE TO STUDENT ASSURANCE SERVICES, INC. ON OR BEFORE THE WAIVER DEADLINE of January 20, 2014.


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 2013-2014 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.

 

Student Information *Required field

*
First Name:
*
Last Name:
*
Student ID: (7 digit account #, from billing statement)
*
Phone Number: (ex. 111-222-3333)
*
Email Address:

 

Other Insurance Information * Required field

*
Other Insurance Co. Name:
*
Address:
*
Phone Number:
*
Subscriber/Policy Number:
*
Policyholder/Subscriber Name:
*
Subscriber Relation:



Electronic Signature

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:

Last Name
First Name

(Parent or guardian if under 18 years of age)

Please re-type your name in the spaces below to confirm your electronic signature:

Last Name
First Name
On (mm/dd/yyyy)

I AGREE

REMINDER: 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.

for waiver

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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