Student Health Insurance Waiver Form
Student Health Insurance Waiver Form
Student ID Number
*
Must be
7
digits.
Currently Entered:
0
digits.
Student Name
Student Name
*
First
Last
Academic Level
*
Academic Level
Undergraduate
Graduate
I am covered under the Following Policy:
Insurance Company:
*
Policy Number:
*
Subscriber Name:
*
Relationship to Student:
*
I will not be joining the Simmons University sponsored health insurance plan. I fully understand that I am legally responsible for any medical expenses during my enrollment at Simmons University, and that Simmons University will not be responsible for any medical expenses.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.