WAIVERS WILL ONLY BE VALID IF SUBMITTED ONLINE ON OR BEFORE THE WAIVER DEADLINE
For Annual or Fall: September 14, 2013 or for Spring January 31, 2014 or for Summer May 15, 2014.


Rockford University Health Insurance Waiver Form.
Students are required to have a health insurance policy in force while attending Rockford College.

I am waiving all rights to participate in the health insurance program that is offered through Rockford University for the 2013-2014 academic year. I understand that by completing this waiver I am stating that I am currently covered under the health insurance plan listed below.

If there is any change in coverage or expiration of coverage, I agree to notify the Lang Center to update the insurance information I have on file.

 

Student Information *Required field

*
First Name:
*
Last Name:
*
Power Campus #: (ex. 123456789)
*
Phone Number: (ex. 111-222-3333)
*
Email Address:
*
 

Undergraduate
Undergraduate/Student Athlete
Graduate
International
International/Student Athlete

During the 2013-2014 academic year I plan to participate in intercollegiate athletics:  Yes   No 

Other Insurance Information * Required field

*
Other Insurance Co. Name:
*
Address:
*
Phone Number:
*
Subscriber/Policy Number:
*
Policy Holder/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
Date (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. There will be absolutely no refunds for insurance after the enrollment period deadline. Any disputes on insurance waivers (waivers submitted after the deadline) must be addressed with the Lang Center.



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