Submit a request – Academic HealthPlans

Please choose your issue below

Your email address

Student Name

First & Last Name

Student ID

Please enter "n/a" if you don't know

Please enter the student’s or subscribers date of birth

By checking this box, I agree the documents submitted contain active coverage and I understand the information submitted will be verified to ensure the plan meets the University’s criteria to waive out of the approved insurance coverage. Please submit your insurance ID card and plan summary

You receive an email confirmation of outcome of the waiver application

Describe your question in a few words:

Please add any additional information or questions (or enter "n/a" if no additional comments)

Attachments

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