Shaw University Insurance Waiver Form

Please Read Before Beginning

Shaw University requires all full-time registered students to have active coverage in order to take classes.
Student Waiver Form

If you are insured individually or through one of your parents, you may elect to waive (decline) the insurance coverage offered by Shaw University.

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 your coverage must exceed or be comparable to the benefits provided under the Shaw University Student Health Insurance 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)

Waiver Criteria

It is required that your insurance cover:

● In-patient and out-patient medical care coverage in North Carolina

● In-patient and out-patient mental health and substance abuse in North Carolina

● Have pharmacy coverage

● Be active, and will cover you while you are within Raleigh, North Carolina (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

After successfully waiving coverage, you will be unable to gain coverage through the Southwestern University insurance policy without a “Qualifying Life Event”. If you experience a Qualifying Life Event, you must notify EIIA at 888.255.4029 within 30 days of losing your coverage to be eligible for special enrollment.

If you need to change any previously submitted waiver information, please contact us for assistance by calling 888-255-4029 or texting 312-620-8902.
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
Please make sure you enter in your correct student ID number, as an incorrect number may cause delays
Date of Birth: * Required
Month
Day
Year
Resident or Home State: * Required
I am an intercollegiate athlete: * Required
Institution: * Required
I agree that I am a student of Shaw University.

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 North Carolina

● In-patient and out-patient mental health and substance abuse in North Carolina

● Have pharmacy coverage

● Be active, and will cover you while you are within Raleigh, North Carolina (or local area where you will be residing and studying for the academic year)
My insurance will cover me while I am at Shaw University * 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 Raleigh, North Carolina (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 Shaw Email Address: * Required
Enter Email Confirm Email
Your Phone Number: * Required
Agreement
By completing this waiver, I agree to the following:
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.
I give EIIA permission to text me if there are questions about my insurance waiver.
Yes, I agree
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.
Confirm Student ID Number: * Required

Step 1 of 4

Please Read Before Beginning

Student Waiver Form

Waiver Criteria

Privacy Policy

Important Information

Student Information

Policy Holder and Insurance Information

Agreement