Submit a request

First & Last Name

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

Iā€™m a full-time AGS employee and elect to waive my AcademicBlue SHIP coverage for the 22-23 plan year from September 1, 2022 ā€“ August 31, 2023. I understand that if I change my mind, I have until October 1, 2022 to enroll in AcademicBlue SHIP for the 22-23 plan year. I also understand that if I become a part-time AGS employee during 22-23, I will be automatically enrolled in AcademicBlue SHIP and have 31 days to waive coverage.

Add file or drop files here