OST Health Insurance Waiver
Date of Application
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Confirm Email
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Company Information
Insurance Company / Government Plan:
*
Insurance Company Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance Company Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Policy Holder's Information
Policy Holder's Name
*
First Name
Last Name
Policy Holder's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Policy Holder's / Subscriber ID Number
*
Policy / Group Number
*
Type a question
Waiver Certification - This waiver is to certify that I, the above named student, am waiving coverage of the health insurance plan offered to me by the Oblate School of Theology. In addition, because I am waiving the CHP health insurance, I am guaranteeing that I will instead be covered by an independent health insurance plan which I will arrange myself.
*
Yes, I Understand
Electronic Signature
*
Submit
Should be Empty: