(An email will be sent to the email address provided, confirming that you have
successfully completed and submitted your online waiver information. If
you do not receive a confirmation email, please contact Student Assurance Services,
Inc. at firstname.lastname@example.org. A waiver receipt form screen will appear after you
complete the waiver form and click on “APPLY for waiver”)
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.
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