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FOR OFFICE USE ONLY Date received ____________ Received by____________ Date Completed____________ Approved Y/N Reason: NC NFC NBC IS CIA
 

Summary: FOR OFFICE USE ONLY
Date received ____________ Received by____________ Date Completed____________ Approved Y/N Reason: NC NFC NBC IS CIA
Student Health Services
10 W. 35
th
Street, Ste 3D9-1
Chicago IL, 60616
P. 312-567-7550 F. 312-567-5702
A COPY OF THE FRONT AND BACK OF YOUR HEALTH INSURANCE CARD MUST BE PROVIDED WITH THIS FORM TO BE
ELIGIBLE TO WAIVE, IT MAY BE FAXED, MAILED OR HAND DELIVERED by September 1st
(Fall) and January 26th
(Spring)
First Name: ______________________________ Middle: ______ Last Name: ______________________________________
CWID: A__________________ Email Address: __________________________________________ International Student Y /N
Waivers will only be granted to those international students (F1 and J1) who have
Health insurance coverage through a US-based employer
I have health insurance that satisfies the conditions listed below and do not wish to purchase the Student Health Insurance Plan.
If your coverage does not meet all five of these criteria of comparable coverage, you may not waive, contact Student Health
Services for more information. If you do not know whether your coverage meets these conditions, contact your health
insurance plan administrator to get current, accurate information about your plan before completing this form.

  

Source: Argamon, Shlomo - Department of Computer Science, Illinois Institute of Technology

 

Collections: Computer Technologies and Information Sciences