WAIVER OF HEALTH AND DENTAL CARE

WAIVER OF HEALTH AND DENTAL CARE You must complete and sign this form if you choose to waive health and dental benefits under your student insurance plan. You may waive health/dental coverage for yourself ONLY if you have coverage through a comparable plan. This coverage is in excess of your provincial health plan. You must attach proof of coverage with this form (photocopy of insurance card, with your name and expiry date; or a letter from the insured individual’s employer confirming your coverage for the academic year). Forms may be returned to the Administration office at room 105. Student ID Number Student Name Employer/Company Name and Insurance Company Name and Division Number Insurance Company Name and Group Division Number Cardholder’s Name Cardholder’s Relationship to Student I hereby waive extended health and dental benefits under the student insurance plan because I have comparable coverage elsewhere. Student’s signature Date signed Crandall Financial Office Date signed Waiver deadlines: September 30 th for September enrollment January 30 th for January enrollment

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 You must attach proof of coverage with this form (photocopy of insurance card, with your name and expiry date; or a letter from the insured individual’s employer confirming your coverage for the academic year). I hereby waive extended health and dental benefits under the student insurance plan because I have comparable coverage elsewhere. Crandall Financial Office Date signed WAIVER OF HEALTH AND DENTAL CARE  Forms may be returned to the Administration office at room 105.

Transcript of WAIVER OF HEALTH AND DENTAL CARE

WAIVER OF HEALTH AND DENTAL CARE

You must complete and sign this form if you choose to waive health and dental benefits under your student insurance plan.

You may waive health/dental coverage for yourself ONLY if you have coverage through a comparable plan. This coverage is in excess of your provincial health plan.

You must attach proof of coverage with this form (photocopy of insurance card, with your name and expiry date; or a letter from the insured individual’s employer confirming your coverage for the academic year).

Forms may be returned to the Administration office at room 105.

Student ID Number Student Name

Employer/Company Name and Insurance Company Name and Division Number

Insurance Company Name and Group Division Number

Cardholder’s Name Cardholder’s Relationship to Student

I hereby waive extended health and dental benefits under the student insurance plan because I have comparable coverage elsewhere.

Student’s signature Date signed Crandall Financial Office Date signed

Waiver deadlines:

September 30th for September enrollment

January 30th for January

enrollment