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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: 04/23/2014