Student Health Insurance Waiver

Student Health Insurance Waiver
SPRING 2010

The deadline to waive the Student Health Insurance Plan for the Spring 2010 term is January 26, 2010.

Student Information

First Name:
Last Name:
Middle Initial:
CWID:	(123-45-678)
Student Status:
U.S. Citizen International Student Country of Origin: Waivers will only be granted to those international students (F1 and J1) who have Health insurance coverage through a US-based employer Health insurance coverage provided by their home country embassy
Email Address:

I have health insurance that satisfies the conditions listed below and do not wish to purchase the Student Health Insurance Plan.

You must indicate that your health insurance plan meets each of the conditions below by selecting the yes option for each statement.
If your coverage does not meet all five of these criteria of comparable coverage, you may not waive online.Contact the Student Health Center for more information. If you do not know whether your coverage meets these conditions, contact your health insurance plan administrator to get current, accurate information about your plan before completing this form.
This waiver form must be completed and submitted before the wavier deadline of the term you wish to waive the student health plan.

Yes	No
		My plan provides coverage for medically necessary care in the Chicago area equivalent to the coverage provided by IIT's student health plan. (Note - HMO's providing emergency coverage only do not meet this requirement).
		My insurance plan provides a maximum benefit coverage of at least $100,000 U.S. dollars.
		My coverage will remain in force as long as I am a full-time registered student at the Illinois Institute of Technology.
		My deductible is $1,000 or less.
		My plan provides coverage for alcohol related injuries and provides mental health coverage.

Insurance Information

Insurance Company:
Subscriber Name:
Insurance Policy Number:
Insurance Company Phone #:	(123-456-7890)

By selecting YES below, I affirm that I have health insurance coverage that meets all five of the conditions described above. I am requesting to waive the IIT Student Health plan. I certify that the information supplied is correct, and I am responsible for any incorrect information, whether intentional or otherwise. I understand I am legally responsible for any medical expenses incurred during my enrollment at the University, and that the University and its medical insurance program will not be responsible for any of my medical expenses. I understand that this information may be checked and verified, and if my plan does not meet these requirements, or I am uninsured, I may automatically be charged for and enrolled in the Student Health Insurance Plan if I am a full time student or live in the Residence Halls.

I understand that this waiver will be valid for each term that I am continually enrolled in classes at IIT and that if I want to be enrolled in the Student Health Plan I will have to notify the Student Health Center in writing.

I understood the statements above: Date: (MM-DD-YYYY)