I have enrolled in the coverage specified on this form and attest to the accuracy of the information above. I will continue to maintain this coverage and will notify UHSA of any changes by submitting a new Proof of Insurance Evaluation Form as notification of those changes. Furthermore, I agree to submit a new Proof of Insurance Evaluation Form as periodically requested by UHSA, whether changes occur in my coverage or not. By signing below, I acknowledge that any fraudulent or misrepresented information herein will result in official student misconduct actions, which could result in suspension/dismissal from UHSA. Upon such findings, UHSA will have no responsibility (legal or financial) for any health issues that apply to and have been incurred by me, including death. By signing below, I also authorize UHSA to investigate the validity of private policy benefits to meet all listed requirements.