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I do not wish to purchase the Drury University International Student Health Plan for 2016-17. 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:
What is the contact information for your insurance company?
By submitting this insurance Waifver Petition form, I am agreeing that I do not wish to purchase the Drury University International Student Health Plan for the Fall 2016 semester.
I understand that in order to complete the waiver process for a review, below items must be submitted to the International Student Office two weeks before the official start date of class:
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 EIIA.
Finally, I understand that granting this Waiver is in the sole and final discretion of Drury University. If the Waiver is granted,I acknowledge that Drury University is unconditionally and absolutely released from any liability concerning my health insurance coverage and I will sign a release form to that effect. I will also be required to accept the EIIA coverage in the event your personal policy expires, is cancelled or is found to lapse.
Please check the box below to agree to the above statement.