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Summary: Medical Student Insurance Waiver Request Form for the
2011-2012 Academic Year
(Use this form to request a waiver of your student health insurance)
Student Information:
Name DOB SSN
Address
Phone Email address:
Waiver Information
· I understand that if I waive the health insurance coverage provided by the Albert Einstein College of Medicine of
Yeshiva University, my dependents (if any) and I will not be entitled to claim any benefits under the plan offered
by the University.
· I understand that this waiver is in effect for the academic year, unless I elect to enroll for coverage beginning
January 1st
due to a qualifying event. I understand that to enroll in the plan, I must complete an enrollment
application.
· I understand that if I lose my current coverage, I must enroll in the health insurance plan within 30 days of the
termination date.
· I understand that I must complete a new waiver form at the start of each academic year otherwise; I will
automatically be enrolled in the health insurance plan.
The following information must be completed before your waiver may be considered. If you answer "no" to any
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