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.
Your First Name and Last name must match the First Name and Last Name provided in "Student Information" above.
Please re-type your name in the spaces below to confirm your electronic signature:
REMINDER: Purchase of individual term coverage will result
in submitting a waiver every fall semester.
A waiver receipt form screen will appear after you complete the waiver form and click on "APPLY for waiver".
This indicates that the waiver has been successfully submitted. Please print the electronic receipt screen or save it
for your records in the event there is a question regarding your waiver submission.
ONCE YOU CLOSE THE ELECTRONIC RECEIPT FILE, YOU CANNOT RETRIEVE IT.
We recommend that you review your UIW student account statement periodically to
insure that proper credit has been issued to your account (credit for waivers
are processed 10 days after deadline period). Any disputes on UIW insurance
waivers (waivers submitted after deadline) must be addressed by Paul Fisher
or via phone 1-210-861-8696.
If you are experiencing any problems with this page please contact