Imagery of Regent people and campus

Waiver Request Form

This form should be completed prior to the application deadline of each semester. If you have any questions, please contact the Business Office at 757.352.4059 or busoff@regent.edu.

* required field
 
* First Name:
Middle Initial:
* Last Name:
 
* Email:
Banner ID:
* International F1/J1 Visa Holder: Yes No
* I am a/an: Graduate Undergraduate
 
I will not be enrolling in the student health insurance plan as I have coverage as listed:
 
* Insurance Company Name:
* Policy/Group Number:
 
* The Policy listed above is my:
Parent's Plan Employer's Plan Spouse's Plan Individual Plan
Please tell us why you chose an alternate plan:
The university-sponsored plan provides more coverage than I want/need.
The university-sponsored plan provides less coverage than I want/need.
The university-sponsored plan is more expensive than I would like.
I am simply happy with my current coverage, and do not wish to make any changes.
 
I fully understand that I am legally responsible for any medical expenses incurred during my enrollment at Regent University. I also understand that should I lose my current health insurance coverage, I will immediately notify the Business Office and make arrangements to join the university student health insurance plan.
 
* Electronic Signature:
Date: 02/13/2012