Pacific University 2013-2014 School Term
Student Health Insurance Waiver Form
The university requires that each student participate in the Student Health Insurance Plan unless proof of comparable coverage is submitted with this completed form. By submitting this information you are providing proof of personal health insurance to apply to the 2013-2014 School Term.
F1 international students are not allowed to use the online waiver. Please click here, print, and complete the waiver form and turn it in to the University Business Office.
Emergency Contact Information
Primary Care Physician (Family Physician)
Health Insurance Information
** By typing your name in the Signature field, you hereby certify that the information entered into this form is true and correct.
You will receive a Waiver ID number confirming this submission.