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
My current policy covers me from July 28, 2014 to July 27, 2015
No
Yes
My policy covers pre-existing conditions?
No
Yes
My current policy provides coverage of medical expenses at a minimum of 80% of the preferred allowance with an unlimited maximum benefit.
No
Yes
My policy covers me when I am on approved rotations in other states.
No
Yes
My current policy covers inpatient and outpatient mental health.
No
Yes
My current policy has prescription drug coverage with a policy year maximum of $1,500 or more.
No
Yes
My policy deductible is $500.00 or less.
No
Yes
Name of Insurance Company
Name of Policy Holder (self, parent or guardian)
Policy Number
Group Number
Customer Service Phone Number
Date of Enrollment in Plan(MMDDYYYY)
*Student Signature (Type your name)
Signature Date (MM/DD/YYYY)
*I hereby waive participation in the Central Michigan University 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