5071 WEST H AVENUE | KALAMAZOO, MI 49009 | 269.381.6630

1st Agency: Chowan University 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 Student Health Insurance Plan MUST complete the online Waiver Form by the due date. 

The Waiver must be completed by: 08/23/2024. The opportunity to waive coverage is limited ONLY to students who have other health insurance.

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

Student Information

Insurance Information

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 verify eligibility 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 Ruth Casper (wommar@chowan.edu) 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. Additionally, I fully understand and agree that any and all costs associated with my healthcare, including costs for services not covered by my insurance, are my responsibility and the college will not be held liable