Insurance Hard Waiver

All William Jessup University full-time undergraduate students, carrying six units or more, are REQUIRED to have health insurance.

Before completing this waiver, please check with your insurance company for verification of all health benefits outside your coverage area.

Please complete this form to WAIVE the William Jessup University Student Health Insurance Plan.

Student Information

Student Last Name *

Student First Name *

Middle Initial

Student Birth Date *

Month

Day

Year

Student Email *

Student ID # *

Insurance Information

Current Insurance Carrier *

Member Services Contact and Phone Number *

Policy Number *

Policy Holder Name *

Relationship of Policy Holder to Student *

Effective Dates of Coverage (From) *

(mm/yyyy)

Effective Dates of Coverage (To) *

(mm/yyyy)

Benefits cover out of state *

Yes

Benefits are effective in the USA *

Yes

Lifetime Maximum Benefit per sickness or injury *

Agreement *

I certify that I am currently participating in the above insurance policy and will continue to participate throughout the school year.

Student Signature *

Jessup News

	William Jessup University 333 Sunset Blvd. Rocklin CA 95765
	(916) 577-2200 (800)355-7522
	information@jessup.edu