WAIVERS WILL ONLY BE VALID IF SUBMITTED ONLINE ON OR BEFORE THE WAIVER DEADLINE
For Annual or Fall: August 17, 2011 or for Spring/Summer: January 11, 2012


St. Ambrose University Health Insurance Waiver Form.
All students are required to have a health insurance policy in force while attending the University.

I am waiving all rights to participate in the health insurance program that is offered through St. Ambrose University for the 2011-2012 academic year. I understand that by completing this waiver and the electronic signature I declare that I have adequate health insurance for the entire 2011-2012 school year and do not wish to participate in this plan. 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 SAU Health Services and update the insurance information I have on file.

 

Student Information *Required field

*
First Name:
*
Last Name:
*
Student ID: (ex. 0123456)
*
Phone Number: (ex. 111-222-3333)
*
Email Address:
*
 

Graduate
Undergraduate

 

Other Insurance Information * Required field

*
Other Insurance Co. Name:



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 (credit for waivers are processed up to 10 days after deadline period). Any disputes on insurance waivers (waivers submitted after the deadline) must be addressed with the Student Health Insurance Coordinator at 563-333-5840.



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