Insurance Waiver Petition

2014-15 Academic Year

Full Name:
Drury ID:
E-mail Address:
Phone Number:

I do not wish to purchase the Drury University International Student Health Plan for 2014-15. In submitting this insurance Waiver Petition form, I fully understand that it is my responsibility to maintain health insurance for myself and my family (if applicable).

Answer YES or NO to each of the following statements about your health insurance plan:

Yes No My plan is currently in force and will remain in force until June 30, 2015 (or beyond). For students graduating May 2015: My plan is currently in force and will remain in force until May 31, 2015 (or beyond). Further, I understand that if this Waiver Petition is accepted by Drury University, I/my insurance company may be contacted to confirm continuous coverage on a periodic basis.
Yes No My plan is a major medical health plan covering me and my family (if applicable), in or out of the hospital. (No "hospital only" or "hospital confinement only" will be accepted.)
Yes No My plan provides a minimum of $250,000 reimbursement per policy year for each insured person.
Yes No I request waiver of the Drury University International Student Health Insurance Plan for 2014-15 because of a Pre-existing Condition.

Please check all that apply:

My plan includes repatriation of remains coverage of at least $25,000.
My plan includes medical evacuation coverage of at least $25,000.
My plan is underwritten by a company licensed to do business in the United States.
My plan is administered by an insurance company with a licensed claims office in the United States.
My scholarship from home country government includes health care.
I will study abroad in the upcoming semester and I have purchased Study Abroad insurance.

NOTE:

By submitting this insurance Waiver Petition form, I am agreeing that I do not wish to purchase the Drury University International Student Health Plan for 2014-15.

I understand that in order to complete the waiver process for a review, three things must be submitted to the International Student Office two weeks before the official start date of class:

1. A photocopy of my insurance card (front and back)
2. A copy of the declarations page (listing the benefits) from my current insurance policy
3. A completed insurance waiver petition (submit this online)
4. A copy of financial guarantee letter (or scholarship letter) for SACM students (and Kuwait students)

I understand that failure to complete this within the deadline will mean I will automatically be charged the current fees for the Drury insurance coverage offered through Seven Corners.

Finally, I understand that granting this Waiver is in the sole and final discretion of Drury University. If the Waiver is granted, I agree release Drury University from any liability for any issue of medical coverage.

If you do agree to the above statement, please select the "I Agree" button and you should receive an online verification that your application has been received.


 
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