Student Accident & Sickness Waiver Form

Accident & Sickness Waiver Form for International Students

2013-2014 STUDENT ACCIDENT & SICKNESS WAIVER FORM FOR INTERNATIONAL STUDENTS
Complete and return this form to: International Student Services • 711 E. Boldt Way, SPC 41 • Appleton, WI 54911
Fax: 1‐920‐832‐7026; Email: internationalhouse@lawrence.edu

Students that have comparable insurance coverage and choose to waive the medical insurance policy offered through Lawrence University must complete this form. If you do not have comparable insurance coverage, you will be automatically billed by the school and covered.

Last Name *

First Name *

Date of Birth *

Year

Month

Day

Address *

I have the following comparable coverage that will remain in effect throughout the academic year:

Name of the Insurance Company *

Address of the Insurance Company *

Policy Number *

Deductible

Please attach a copy of your insurance card *

Please enclose a copy of what your insurance policy covers *

Electronic Signature *

Date *

Year

Month

Day

CAPTCHA

This question is included to prevent automated spam submissions. Please attempt to type the words below into the text box provided.

Incorrect please try again

Enter the words above: Enter the words you hear: