Westminster Theological Seminary

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Home » Becoming a Student » Applying To Westminster » Health Insurance » Insurance Forms » Waiver

Waiver

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STUDENT HEALTH INSURANCE WAIVER FORM
2008-2009

For FULL-TIME STUDENTS who are NOT participating in the Westminster-sponsored health insurance plan: You must complete and return this form (ALONG WITH a copy of the front of your insurance card or letter from your insurance company) to the Student Affairs office by Friday, Sept 5th (first week of classes).

SECTION 1:

STUDENT INFORMATION

* Last Name
* First Name
US Social Security Number
Email

Address1
Address2
State
Zip Code
Country
Phone

I understand that I must have health insurance to be enrolled as a full-time student at Westminster
Theological Seminary. I will not be joining the Seminary’s sponsored student insurance plan
because I have comparable coverage through the following group or private policy:

INSURANCE COMPANY

POLICY #

I fully understand that I am legally responsible for any medical expenses. I promise to maintain
my health insurance coverage while a full-time student or, if my medical insurance protection is
terminated, I promise to enroll in another health insurance plan and submit a waiver form to
the Student Affairs office within 3 weeks (21 days) of said termination.
I understand that this waiver is only valid when accompanied by 1) a copy of the front of my
insurance card or 2) a signed letter from my insurance company. I have provided this.
I further understand that this waiver is effective through September 1, 2009 and must be renewed
at the start of each academic year.

SECTION 2 (to be signed by J-1 and F-1 VISA students only):

Int’l student on J-1 or F-1 VISA?

Yes No

I have Medical Evacuation and Repatriation of Remains (MERR) coverage as evidenced by the
copy of my policy, which I am submitting along with this form.