RHIT Waiver Form - EIIA Member Portal

DEMO

Please Read Before Beginning

Rose-Hulman Institute of Technology requires all full-time registered students taking 1 or more credit hours to have active coverage.

International students are not eligible to waive. Please contact Insurance & Risk Management at simonson@rose-hulman.edu with questions.

Student Waiver Form

If you are insured individually or through one of your parents, you may elect to waive the insurance coverage offered by Rose-Hulman Institute of Technology. International students, regardless of registration status, are not permitted to waive the Rose-Hulman Institute of Technology student insurance.

You must provide ALL of the necessary information below and answer the questions to successfully waive this coverage.

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)

Waiver Criteria

It is required that your insurance cover:

● In-patient and out-patient medical care coverage in Indiana

● In-patient and out-patient mental health and substance abuse in Indiana

● Have pharmacy coverage

● Be active and will cover you while you are within Terre haute, Indiana (or local area where you will be residing and studying for the academic year)

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.

Important Information

Student Insurance may be added or deleted at the start of any quarter.

If you need to change any previously submitted waiver information, please contact Insurance & Risk Management at simonson@rose-hulman.edu
Are you an international student? * Required
- No
- Yes
International students are not eligible to waive. Please contact Insurance & Risk Management at simonson@rose-hulman.edu with questions.
Agreement: * Required
I have read the above information and wish to continue
- Yes

Student Information
First Name: * Required
Last Name: * Required
Student ID Number: * Required
Enter ID Confirm ID

Please make sure you enter in your correct student ID number, as an incorrect number may cause delays
Date of Birth: * Required
MM slash DD slash YYYY
Resident or Home State: * Required
I am an intercollegiate athlete: * Required
Institution: * Required
I agree that I am submitting a waiver for a student of Rose-Hulman Institute of Technology

Policy Holder and Insurance Information
Policy Holder First Name: * Required
Policy Holder Last Name: * Required
Insurance Company Name * Required
Please choose the best option for your carrier. For example, if you have Anthem BCBS Connecticut, please select Blue Cross & Blue Shield (BCBS). If you have Aetna Better Health, please select Aetna. If your carrier is not included please select ‘Other.’
Insurance Company Name * Required
Your Insurance Company was not on the list, please type in the name of your carrier.
Insurance Company ID Number: * Required
Insurance Company Group Number:
Insurance Company Phone Number: * Required
Waiver Criteria

It is required that your insurance cover:

● In-patient and out-patient medical care coverage in Indiana

● In-patient and out-patient mental health and substance abuse in Indiana

● Have pharmacy coverage

● Be active and will cover you while you are within Terre Haute, Indiana (or local area where you will be residing and studying for the academic year
My insurance will cover me while I am at Rose-Hulman Institute of Technology * Required
- No
- Yes
It is required that your insurance cover you for routine, non-emergency care, as well as emergency care while you are within the City and State of Terre Haute, Indiana (or local area where you will be residing and studying for the academic year). It is likely that your waiver will not be approved.
I have Medicaid Coverage: * Required
- No
- Yes
Out of state Medicaid will not be accepted.

Your Email: * Required
Enter Email Confirm Email
Your Phone Number: * Required
Agreement
By completing this waiver, I agree to the following: * Required
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 (i.e., “Qualifying Life Event”). I also understand that by waiving this coverage I am financially responsible for any medical charges.
Would you like EIIA to have permission to talk to your parents:
Yes, I would like EIIA to have permission to talk to my parents regarding my insurance.

Step 1 of 4

DEMO

Please Read Before Beginning

Student Waiver Form

Waiver Criteria

Privacy Policy

Important Information

Student Information

Policy Holder and Insurance Information

Agreement