Stetson University School of Law All Students Insurance Opt-Out Waiver Form

Stetson University School of Law All Students
Insurance Opt-Out Waiver Form

(mm/dd/yyyy)

Please Respond To the Following Statements

1. My plan provides continuous coverage, and I am eligible to receive such coverage for the entire spring and summer 2012 semesters.
2. My plan provides coverage for at least $100,000 per injury/illness per academic year.
3. My plan provides coverage for services rendered at hospitals, physicians, pharmacies, and mental health care providers within a 50 mile radius of my residence in the State of Florida.
4. My plan provides coverage for lab work, diagnostic x-rays, and prescriptions within a 50 mile radius of my residence in the State of Florida.
5. My insurance carrier is a company based in the United States, and hospitals and doctors will be able to bill them directly.
6. My plan provides coverage for Alcoholism and Drug Abuse.
7. My plan provides coverage for pregnancy.
spacer
Answering “no” to any of the above will likely trigger an additional inquiry on plan details to determine whether your plan can be approved. Please promptly cooperate to avoid approval delays.

Current Health Insurance Plan Information
(typically found on your insurance card)

Claims
Primary Insured
Must be located in the U.S. As listed on Insurance ID Card

Opt-Out Eligibility Requirements

To indicate your acknowledgment of the following requirements, please click the checkbox to the left of each item:

I am currently covered by the above-mentioned plan and the representations checked are accurate;
My plan is NOT a travel or an emergency-only plan;
If my plan has a deductible, I have adequate financial resources available to pay for the charges subject to the deductible;
I have verified my plan provides full coverage in the State of Florida (within a 50 mile radius of my local Florida address) with my health insurance plan representative.
If the above noted policy is terminated, I will notify Stetson University College of Law at This email address is being protected from spambots. You need JavaScript enabled to view it. and make arrangements to enroll in other insurance immediately.

I acknowledge the insurance requirements established by Stetson University College of Law (available at www.law.stetson.edu/policies/home) and agree to abide by them. Alternate insurance policies are approved for limited periods not exceeding one year and that the requirements for alternate policy coverage are subject to change. I understand that I must have my policy reviewed at the end of each annual approval period.

I also understand that if alternate insurance is not approved, this does not mean that Stetson University College of Law or any of its employees recommend that I cancel any existing, pending or proposed insurance coverage. A denial implies only that the policy presented does not meet the minimum criteria established by Stetson University College of Law with respect to specific medical insurance coverage criteria for registration and/or enrollment.