Collegiate Risk Management - Affordable Student Health Insurance
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*First Name
Initial
*Last Name
*Student ID
*Date of Birth (MM/DD/YYYY)
*Email
Did you complete a waiver for Fall and was it accepted?
No
Yes
If No - please complete all remaining questions.
If Yes - only answer required fields *.
My current policy covers me to August 14, 2015.
No
Yes
Do you have coverage at a minimum of 80% of the preferred allowance, with no maximum benefit?
No
Yes
My policy covers pre-existing conditions?
No
Yes
Your current policy deductible must be no higher than $1,000. What is your current deductible?
My current policy covers inpatient and outpatient mental health?
No
Yes
My current plan has prescription drug coverage with a policy year maximum of $1,500 or more?
No
Yes
My current plan provides coverage in the Decatur/Atlanta area?
No
Yes
My current plan provides wellness visit benefits with no cost sharing?
No
Yes
Name of Insurance Carrier
Name of Policy Holder (self, parent or guardian)
Policy Number
Group Number
Customer Service Phone Number
Date of Enrollment in Plan (MM/DD/YYYY)
*Student Signature (Type your name)
Signature Date (MM/DD/YYY)
*I hereby waive participation in the Agnes Scott College Student Health Insurance Plan and certify that I have coverage that is comparable to the student insurance plan as indicated. I acknowledge that I am legally responsible for any and all bills.
No
Yes
Questions?
800-922-3420
Waiver