St. Mary's University
Student Health Insurance Summer 2014, Domestic Online Waiver
Deadline for Submission: May 30, 2014
The university requires that each dormitory student, athlete and international student participate in the Student Health Insurance Plan unless proof of comparable coverage is submitted. If you are a domestic U.S. born student, please complete the waiver below. By submitting this information you are providing proof of personal health insurance to apply to the 2013-2014 academic year.
If you are an international student (including international athletes), please do not complete the waiver below. You must go back to the previous page and click on International students on the right side of the screen and follow the instructions provided.
Emergency Contact Information
Primary Care Physician (Family Physician)
Health Insurance Information
I hereby submit proof of personal health insurance and decline the St. Mary's University sponsored Student Health Insurance Plan. I acknowledge that I am legally responsible for any and all medical expenses incurred by myself/dependant while enrolled.
I know it is a crime to fill out this form with facts I know are false or leave out facts I know are important. I certify that the information furnished by me is true and correct. I further agree to notify St. Mary's University or St. Mary's University Athletics Department immediately in writing if my insurance policy expires or changes during my attendance.
Please be advised that it is your responsibility to enroll in the Student Health Insurance Plan or find comparable health coverage if your insurance status changes. You can contact Academic HealthPlans at 855-357-0238 should you need any information on the St. Mary's University Student Health Insurance Plan
** 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 Email confirmation of this submission.