Summary: AHC Student Health Benefit Plan
2011-2012 Waiver Request Form
Please submit to: Office of Student Health Benefits, 410 Church Street S.E., N323, Minneapolis, MN 55455. Fax: (612) 626-5183 or 1-800-624-9881.
Please keep a copy of this form for your records. For more information, visit the Office of Student Health Benefits website at www.shb.umn.edu.
To request a waiver from the University-sponsored AHC Student Health Benefit Plan, submit this form to the Office of Student Health Benefits
along with proof of coverage. All eligible students must complete the waiver request process by the Twin Cities campus class registration deadline
(this deadline can be found on the One Stop website). Please keep a copy of this form for your records.
A. Student Information
Name (Last, First, Middle Initial) (Please Print) Date of Birth (mm/dd/yyyy) Gender U of M ID Number
Street Address, City, State, Zip Code Daytime Phone Email Address
Campus (check one): ___ Duluth ___ Rochester ___ Twin Cities
B. Health Plan Information--which type of health plan do you have?
___ A United States-based employer-sponsored group health plan--Students who select this option must also submit proof of coverage in the
form of a Certificate of Coverage, also called a letter of active coverage, obtained from your insurance company (a copy of your insurance card
is not acceptable verification of coverage to obtain a waiver).
___ Minnesota Care-- Students who select this option must also submit proof of coverage in the form of a Certificate of Coverage, also called a