Collegiate Risk Management - Affordable Student Health Insurance
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First Name
Middle Initial
Last Name
MU ID Number (Enter MU then number if ID begins with 0))
Social Security Number
Date of Birth (MM/DD/YYYY)
Email
My current policy covers me from August 1, 2013 to August 1, 2014?
No
Yes
Do you have coverage at a minimum of 80% of the preferred allowance, up to a maximum of at least $500,000?
No
Yes
My policy covers pre-existing conditions?
No
Yes
My policy deductible is $1,000 or less?
No
Yes
My current policy covers inpatient and outpatient mental health?
No
Yes
My current plan has prescription drug coverage?
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 (MMDDYYYY)
Student Signature (Type your name)
Signature Date
I hereby waive participation in the Methodist 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
Questions?
800-922-3420
Methodist University Waiver