Student Insurance, Athletic Accident Coverage, Special Risk Insurance, Summer Camps, Little Leagues

1st Agency: Belmont Abbey College Waiver Form

Complete this form ONLY if you have Proof of Alternate Health Insurance. NOTE: Your insurance must be valid and accepted in the Greater Charlotte/Mecklenburg County area.

Students who have other coverage and are waiving out of the Student Health Insurance Plan MUST complete the online Waiver Form below and include a copy of your insurance card (front and back) by the due date.

The Waiver must be completed by 01/19/2024. The opportunity to waive coverage is limited ONLY to students who have other health insurance that is valid in the Greater Charlotte/Mecklenburg County area.

Required items are indicated with an asterisk (*). You MUST click the Submit Button to complete the form.

School Year *

School Name *

Student Information

Student ID Number *

First Name *

Date of Birth *

Gender *

Male Female

Middle Initial

Last Name *

Title

Address Line 1 *

Address Line 2

City

Postal / Zip Code *

County

State / Province / Region

Country

Phone Number *

Will you be a member of an NCAA-sponsored intercollegiate sports team at Belmont Abbey College?

Yes No

Email Address *

Insurance Information

Insurance Carrier *

Benefit Effective Date *

Policy Number / Group Number *

Family Deductible Amount *

Name of Primary Insured *

Primary Insured's Date of Birth *

Student's Relation to Primary Insured *

Individual Deductible Amount *

Check ALL Coverage that Applies

MEDICAL

DENTAL

VISION

Phone Number of Insurance Carrier *

Insurance Card Upload

Attach a File : Front of Insurance Card *

Attach a File : Back of Insurance Card *

Comment

1st Agency: Belmont Abbey College Waiver Form

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