University of the Cumberlands | Student Insurance

UNIVERSITY OF THE CUMBERLANDS
STUDENT MEDICAL INSURANCE WAIVER

The University of the Cumberlands permits you to waive out of the student health insurance plan only if you have adequate coverage under another health care plan that meets the University’s requirements. This waiver must be completely filled out with accurate information and must be accompanied by proof of insurance. The University reserves the right to accept or reject this waiver and to contact the insurance company listed below to verify this information. (You may be required to provide a copy of the front and back of the current insurance card for verification purposes)

Student Information

Student's First Name

Student's Middle Name

Student's Last Name

/ /

Student's Birthdate

Student ID #

Student's SSN

( ) -

Email Address

Home or Campus Phone Number

Cell Phone Number

Is this student participating in intercollegiate sports at UC? Yes No

Is your insurance a State Medicaid program? Yes No

--Medicaid is a federal system of health insurance for those requiring financial assistance. For more information on Medicaid, see http://www.cms.gov/MedicaidGenInfo/

Note: Medicaid programs and Tricare Prime do not meet the minimum coverage requirements for students participating in athletics. Tricare Standard with supporting documents may meet the minimum coverage requirements for students participating in athletics.

In order for your insurance plan to be eligible for this waiver, it must meet the following minimum requirements:

Offers at least 60% coverage for inpatient and outpatient medical services in the Williamsburg, KY area.
If a deductible is in place, it must not exceed $5,000 per year
Offers medical benefits of at least $ 25,000 per injury or illness (plans that provide benefits for emergency care only are not acceptable)
Provides coverage for inpatient and outpatient medical services for injuries or illnesses sustained in intercollegiate sporting events (if participating in any intercollegiate sport activities).
Provides direct claim payment to providers (plans that offer reimbursement only to an individual for claims incurred are not acceptable).

Policy Holder Information

Policy Holder's Relationship to Student

/ /

Policy Holder's Name

Policy Holder's Birthdate

Policy Holder's SSN

Policy Holder's Address

City

State

Zip

Insurance Company's Information

( ) -

Insurance Company

Insurance Co. Phone Number

Group Number

Insurer's Plan Number

Policy Number

Information about Person Submitting this Form

What is your relationship to the student?

( ) -

Your Name

Your Email Address

Your Phone Number

Verification and Submission

I certify that I am currently a member of the health insurance plan identified above and that the plan meets the minimum requirements listed above.

I (or undersigned parent / guardian) fully understand that I am legally responsible for any medical expenses incurred during my enrollment at the University of the Cumberlands. The signature of a parent / guardian is required if the student is under age 18.

Student Signature

Parent Signature (if applicable)

Date

UNIVERSITY OF THE CUMBERLANDS STUDENT MEDICAL INSURANCE WAIVER

UNIVERSITY OF THE CUMBERLANDS
STUDENT MEDICAL INSURANCE WAIVER