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If you are insured individually or through one of your parents, you may elect to waive the insurance coverage offered by your institution. You must provide ALL of the necessary information below and answer the questions to successfully waive this coverage. Your primary insurance coverage must cover you throughout the entire academic year and exceed or be comparable to the benefits provided under this plan. Please have the following information available: ● Student Information (including your student ID number) ● Policyholder’s information, if it is not you (name and telephone number) ● Insurance company information (name, phone number and ID number) PRIVACY POLICY: The personally identifiable information that you provide through this secure website is made available only to authorized agents of your institution and EIIA for a period of one (1) year. If you need to change any previously submitted waiver information, please contact us for assistance. Terms & Conditions Statement (w/ checkbox): I have reviewed the brochure and understand that by waiving this coverage I am financially responsible for any medical charges. I also acknowledge that I cannot opt-in to this plan unless I involuntarily lose coverage.
First Name
*
Required
Last Name
*
Required
Student ID Number
*
Required
Date of Birth
*
Required
MM slash DD slash YYYY
Resident or Home State
*
Required
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Policy Holder Last Name
*
Required
Policy Holder First Name
*
Required
Insurance Company Name
*
Required
Insurance Company Phone Number
*
Required
Insurance Company ID Number
Medicaid
Yes
No
OUT OF STATE MEDICAID WILL NOT BE ACCEPTED
Hidden
Post Tag
Separate tags with commas
Insurance Coverage
My insurance will cover me (i.e., routine, non-emergency care, as well as emergency care) while I am in City, State (or local area where student will be residing and studying for the academic year).
Yes
No
Your Email
*
Required
Enter Email
Confirm Email
Institution
*
Required
Demo University
I agree that am a student of Demo University.
Consent
*
Required
By completing this waiver, I agree to the following:
I agree that the above information is true and correct to the best of my knowledge. I understand that I will not be able to be added to this policy unless I have involuntarily lost coverage.