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Stetson University Deland Domestic Students Insurance Opt-Out Waiver Form

Stetson University Deland Domestic Students
Insurance Opt-Out Waiver Form

(mm/dd/yyyy)

Please Answer the Following Questions

1. Do you have a plan that will provide coverage for sickness and accident with local physicians, hospitals, pharmacies, and mental health care providers in the local Stetson University/Central Florida area?
2. Do you have a plan that will provide coverage for the entire academic year?
3. Do you have a plan that provides a coverage limit of at least $100,000 per injury/accident?
4. Do you have a plan that provides coverage for lab work, diagnostic x-rays, physical therapy, and prescriptions in the Stetson University/Central Florida area?
5. Does your plan allow coverage for pre-existing medical conditions?
If you answered “no” to any of the above, you should consider taking the campus student insurance plan, and in certain circumstances may be required to (i.e., adequate coverage in the Stetson/Central Fla area). Note: This plan can also act as a secondary insurance to cover some of the benefits that your current plan may not cover.

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:

You are currently covered by the above insurance policy;
Your plan is NOT a travel or emergency-only type plan;
If your plan has a deductible in excess of $250, you have adequate financial resources available to pay for the charges under the deductible;
You have verified with you health insurance representative that your plan provides sickness and accident coverage in the Stetson University/Central Florida area.
If the above policy is terminated, you will be required to enroll in the campus plan. Should this happen, please contact Insurance For Students at This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1-800-356-1235.