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.
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 (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.
If you are experiencing any problems with this page please contact the webmaster.