Collegiate Risk Management - Affordable Student Health Insurance
Home
News
Contact Us
Schools
Insurance
International
Specialty Programs
About Us
Blog
Enter School Name:
Follow Us:
facebook
twitter
you-tube
*url:
*email:
My parent or spouse is living/working in the US and has medical insurance coverage for me?
No
Yes
I am a sponsored student and have medical insurance coverage from my sponsoring agency or home government.
No
Yes
I have insurance coverage from my home, family or spouse.
No
Yes
First Name
Middle Name
Last Name
TSU ID Number (include the "T")
Email
Phone Number:
Visa Type
Date of Birth (MM/DD/YYYY)
Gender
Do you have coverage of at least $250,000 per year?
No
Yes
Is your deductible less than or equal to $500?
No
Yes
Does your policy provide continuous coverage during academic semesters, breaks and vacations?
No
Yes
Does your policy cover repatriation up to $25,000?
No
Yes
Does your policy cover evacuation up to $25,000?
No
Yes
Name of Insurance Company
Address of Carrier
Policy Number
Group Number
Coverage Start Date (MM/DD/YYYY)
Coverage End Date (MM/DD/YYYY):
Policy Holder (SACM Cultural Mission, Group, Parent or Guardian)
Customer Service Phone Number
Student Signature (Type your name)
Signature Date (MM/DD/YYYY)
I hereby waive participation in the TSU Health Insurance Plan and certify that I have coverage that is comparable to the student insurance plan as indicated. I certify the information submitted is complete and accurate to the best of my knowledge.
No
Yes
I understand that I am required to maintain health insurance for the full year. By signing above, I agree to purchase the University sponsored plan should my waiver be denied and I acknowledge that I am legally responsible for any and all medical bills.
No
Yes
Questions?
800-922-3420
TSU Waiver