Waiver

*First Name

Initial

*Last Name

*Student ID

*Date of Birth (DDMMYYYY)

*Email

Do you have Medical Benefits of at least $50,000 per accident or illness?

No

Yes

Do you have Repatriation coverage of at least $7,500 and Medical Evacuation coverage of at least $10,000?

No

Yes

Do you have an individual deductible that does not exceed $500 per policy year?

No

Yes

Is your coverage in effect for the semester or academic year while attending classes?

No

Yes

What is your co-pay for Physician visits?

What is your co-pay for Urgent Care visits?

*I hereby waive participation in the Oglethorpe University 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

Name of Insurance Carrier

Group of Identification Number

*Student Signature