WAIVER FORM

Complete this form ONLY if you have Proof of Alternate Health Insurance.

Students who have other coverage and are waiving out of the Crown College Student Health Insurance Plan MUST complete the online Waiver Form.  The Waiver must be completed by: 9/5/08.

Failure to complete and submit the Waiver will require your responsibility of the full premium payment as added to your tuition account. Required fields are indicated with an asterisk (*). You MUST click the Submit button to complete this form.
School Year:*  
School Name:*  
STUDENT INFORMATION:
Student ID Number:*  
First Name:*  
Middle Initial:  
Last Name:*  
Title:
(Jr., Sr., II, III, IV)		  
Date of Birth:*   / /
(Please fill out in numerical format)
Gender:*   MALE FEMALE
Address 1:*  
Address 2:  
City:*  
State:*  
Zip Code:*  
County:  
Contact Phone Number:*  
E-Mail Address:*  
INSURANCE INFORMATION:
Insurance Carrier:*  
Check ALL Coverage that Applies:  
Benefit Effective Date:*   / /
(Please fill out in numerical format)
Policy Number:*  
Name of Primary Insured:*  
Relation to Primary Insured:*  
Phone Number of Insurance Carrier:*  

I have read and understand the Waiver Insurance requirements and agree to maintain health insurance during my enrollment at this educational institution. I authorize my institution and its representatives to eligibility verification and benefit information as necessary to process this Waiver.  I fully understand that if my current healthcare coverage becomes terminated, it is my responsibility to immediately advise the Health Clinic of my status change. I understand that if I enter any information on this form that is fraudulent, I will become disqualified to waive the automatic coverage provided by my educational institution and will be responsible for full premium payment as added to my tuition account.

By clicking the SUBMIT BUTTON below I acknowledge that the above information is correct and I have read and understand the Waiver process as described above.

 
   


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