Student Insurance Waiver Form

General Information

Please fill in the form using the text boxes below.

(Student Name), (Student ID), a full-time registered student at Lycoming College, is covered by medical insurance under policy/certificate # (Policy/Certificate #) as provided by (Name of Company) in the name of (Parent/Guardian).

Plan II is hereby waived for medical insurance offered by the Lycoming College Plan. By typing your name below, you are electronically signing this waiver form.

* If you don't know your student ID, log onto WebAdvisor and under "Academic Profile" select "My Student Information".

ATTENTION: For students who are covered on a parent or guardian's health insurance plan, consider contacting the plan provider to review available network coverage and options for the student while enrolled at Lycoming College.