WAIVERS WILL ONLY BE VALID IF SUBMITTED ONLINE TO STUDENT ASSURANCE SERVICES, INC. ON OR BEFORE THE STATED WAIVER DEADLINE PUBLISHED IN THE RESPECTIVE COURSE SCHEDULE FOR THE ACADEMIC YEAR STATED BELOW


University of the Incarnate Word Health Insurance Waiver Form.
Domestic Students Only - International Students are not allowed to waive coverage
per University of the Incarnate Word policy.

I am waiving all rights to participate in the health insurance program that is offered through the University of the Incarnate Word for the 2013-2014 academic year. I understand that by completing this waiver I am assuming full responsibility for any expenses incurred in connection with any accident or sickness.

I agree to provide true and correct information. I understand that any information I provide that is incomplete or inaccurate will prevent the University from processing my waiver, and will result in the insurance fee being added to my Student Account Statement. I also agree that I am bound by University deadlines posted in the Schedule of Classes (Academic Calendar). I understand that all waiver credits will be posted 10 days after the first day of classes and credit can be confirmed by reviewing my Student Account Statement online.

The University of the Incarnate Word takes no responsibility for the accuracy or submission of Insurance Waiver Forms. Students are responsible for accurate and timely submission of the Waiver Form in order to have the insurance fee removed from their account.

 

Student Information * Required field

* First Name:
* Last Name:
* UIW Student ID:
(Use your school-assigned ID number, not your Social Security Number)
* Phone Number: (ex. 111-222-3333)
* Email Address:
  (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.)

 

Other Insurance Information * Required field

* Other Insurance Co. Name:
* Address:
* Phone Number:
* Policy Number:
* 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.
Your First Name and Last name must match the First Name and Last Name provided in "Student Information" above.

Last Name First Name


Please re-type your name in the spaces below to confirm your electronic signature:
Last Name First Name
On (mm/dd/yyyyy)

I AGREE

REMINDER: Purchase of individual term coverage will result in submitting a waiver every fall semester.

for waiver

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 at: paul@psihealthplans.com
or via phone 1-210-861-8696.



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