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FOR OFFICE USE ONLY Date received ____________ Received by____________ Date Completed____________ Approved Y/N Reason: NR CFS
 

Summary: FOR OFFICE USE ONLY
Date received ____________ Received by____________ Date Completed____________ Approved Y/N Reason: NR CFS
Student Health Services
10 W. 35th
Street, Ste 3D9-1
Chicago, IL 60616
P. 312-567-7550 F. 312-567-5702
Student Health Insurance Enrollment Form 2011-2012
The deadline to enroll is September 1st
(Fall semester)
First Name: ____________________________ Middle: ______ Last Name: ____________________________
CWID: A___________________________ Email Address: __________________________________________
F1 or J1 visa holder Y / N
I am registered for ________ credit hours
I would like my waiver to be taken off of my account Y / N
I am requesting that student health insurance from IIT be added to my student tuition account at a cost of
$830. I understand that the effective period is from August 14, 2011 August 13, 2012. Student Health
Services (SHS) cannot grant appointments to non-IIT students including recent graduates. Exceptions to this
policy must be approved by SHS. The Student Health Insurance plan can be used with any health professional;
it is an open choice PPO. I understand I am legally responsible for any medical expenses incurred during my

  

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

 

Collections: Computer Technologies and Information Sciences