Southern Connecticut State University Health Insurance Waiver Form
Waiver Deadline Date: 09/15/2025
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Personal Information
For questions about the insurance plan or waiver process, please contact ISO at (800) 244-1180 or waivers@isoa.org. Office hours are Monday to Friday, 9am to 6pm EST.
Student Personal Information
First name
Last name
E-mail address
Gender
Male
Female
Date of birth
Student ID or passport number
U.S. Contact Information
U.S. Address
Zip code
City
State
State
Address
Address (optional)
Phone number (mobile)
Phone number (home)
{"ID":640,"FormID":24,"ElementOrder":1,"ElementType":6,"Prompt":"Alternate Insurance","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":6,"Name":"SectionHeader"}}
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2
Alternate Insurance
{"ID":641,"FormID":24,"ElementOrder":15,"ElementType":1,"Prompt":"Please note: The university and its agents have the right to audit and confirm your policy and coverage information.","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":1,"Name":"DisplayText"}}
Please note: The university and its agents have the right to audit and confirm your policy and coverage information.
{"ID":642,"FormID":24,"ElementOrder":16,"ElementType":2,"Prompt":"Full name of insurance company","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
Full name of insurance company
{"ID":643,"FormID":24,"ElementOrder":17,"ElementType":2,"Prompt":"Insurance company address","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
Insurance company address
{"ID":644,"FormID":24,"ElementOrder":18,"ElementType":2,"Prompt":"Insurance company phone number","Options":"","Mandatory":true,"RegExToSubmit":"([0-9]{3})?[-.â—]?([0-9]{3})[-.â—]?([0-9]{4})","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
Insurance company phone number
{"ID":645,"FormID":24,"ElementOrder":19,"ElementType":7,"Prompt":"Your policy effective date","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":7,"Name":"Date"}}
Your policy effective date
{"ID":646,"FormID":24,"ElementOrder":20,"ElementType":7,"Prompt":"Your policy termination date","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":7,"Name":"Date"}}
Your policy termination date
{"ID":647,"FormID":24,"ElementOrder":21,"ElementType":2,"Prompt":"Your policy number","Options":"","Mandatory":true,"RegExToSubmit":"([a-zA-Z0-9_]","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
Your policy number
{"ID":648,"FormID":24,"ElementOrder":22,"ElementType":4,"Prompt":"Does this insurance company have a U.S. based office for submitting claims?","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Does this insurance company have a U.S. based office for submitting claims?
Yes
No
{"ID":649,"FormID":24,"ElementOrder":23,"ElementType":4,"Prompt":"Relationship to policyholder","Options":"Self, Parent, Spouse, Guardian, Employer","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Relationship to policyholder
Self
Parent
Spouse
Guardian
Employer
{"ID":650,"FormID":24,"ElementOrder":24,"ElementType":2,"Prompt":"First name of policyholder (If \"self\" your name)","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
First name of policyholder (If "self" your name)
{"ID":651,"FormID":24,"ElementOrder":25,"ElementType":2,"Prompt":"Last name of policyholder (If \"self\" your name)","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
Last name of policyholder (If "self" your name)
{"ID":652,"FormID":24,"ElementOrder":26,"ElementType":6,"Prompt":"Insurance Benefits","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":6,"Name":"SectionHeader"}}
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3
Insurance Benefits
{"ID":653,"FormID":24,"ElementOrder":27,"ElementType":1,"Prompt":"Does your insurance provide the following benefits:","Options":"","Mandatory":false,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":1,"Name":"DisplayText"}}
Does your insurance provide the following benefits:
{"ID":654,"FormID":24,"ElementOrder":28,"ElementType":4,"Prompt":"Insurance is valid for the entire duration of your program?","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Insurance is valid for the entire duration of your program?
Yes
No
{"ID":655,"FormID":24,"ElementOrder":29,"ElementType":4,"Prompt":"Provides medical benefits of at least $100,000 per accident or illness","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Provides medical benefits of at least $100,000 per accident or illness
Yes
No
{"ID":656,"FormID":24,"ElementOrder":33,"ElementType":4,"Prompt":"Offers repatriation benefits of at least $25,000","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Offers repatriation benefits of at least $25,000
Yes
No
{"ID":657,"FormID":24,"ElementOrder":34,"ElementType":4,"Prompt":"Offers medical evacuation benefits of at least $50,000","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Offers medical evacuation benefits of at least $50,000
Yes
No
{"ID":658,"FormID":24,"ElementOrder":41,"ElementType":4,"Prompt":"Offers a deductible that does not exceed $500 per accident or illness","Options":"Yes, No","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Yes","CssClass":"","Type":{"ID":4,"Name":"MultipleChoice"}}
Offers a deductible that does not exceed $500 per accident or illness
Yes
No
{"ID":659,"FormID":24,"ElementOrder":43,"ElementType":4,"Prompt":"Are you a student athlete? If yes, you will be required to show proof of coverage for athletic injuries","Options":"Yes, No","Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":4,"Name":"MultipleChoice"}}
Are you a student athlete? If yes, you will be required to show proof of coverage for athletic injuries
Yes
No
{"ID":660,"FormID":24,"ElementOrder":44,"ElementType":2,"Prompt":"Reason for waiving insurance","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"","CssClass":"","Type":{"ID":2,"Name":"Text"}}
Reason for waiving insurance
{"ID":661,"FormID":24,"ElementOrder":45,"ElementType":2,"Prompt":"This waiver form is completed by","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":2,"Name":"Text"}}
This waiver form is completed by
{"ID":662,"FormID":24,"ElementOrder":46,"ElementType":5,"Prompt":"By submitting this waiver request, I understand that I am requesting not to be enrolled in the health insurance offered by ISO and Southern Connecticut State University. I certify that I have health insurance which will cover my medical costs while I attend the Southern Connecticut State University. The University will not be held responsible for expenses related to my health and medical care.","Options":"","Mandatory":true,"RegExToSubmit":"","ApprovedValues":"Checked","CssClass":"","Type":{"ID":5,"Name":"CheckBox"}}
By submitting this waiver request, I understand that I am requesting not to be enrolled in the health insurance offered by ISO and Southern Connecticut State University. I certify that I have health insurance which will cover my medical costs while I attend the Southern Connecticut State University. The University will not be held responsible for expenses related to my health and medical care.
{"ID":663,"FormID":24,"ElementOrder":47,"ElementType":5,"Prompt":"I know the University and/or its agents has the right to request in writing evidence of health insurance coverage. Evidence of such coverage can be furnished by submitting the front and back of your health insurance ID card, a copy of the insurance policy and a letter from the insurance company confirming coverage is in effect during your period of enrollment and proof of coverage for dependents, if applicable. ","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":"Checked","CssClass":null,"Type":{"ID":5,"Name":"CheckBox"}}
I know the University and/or its agents has the right to request in writing evidence of health insurance coverage. Evidence of such coverage can be furnished by submitting the front and back of your health insurance ID card, a copy of the insurance policy and a letter from the insurance company confirming coverage is in effect during your period of enrollment and proof of coverage for dependents, if applicable.
{"ID":664,"FormID":24,"ElementOrder":48,"ElementType":1,"Prompt":"If you have any questions, please contact ISO at (800) 244-1180 or waivers@isoa.org","Options":null,"Mandatory":true,"RegExToSubmit":null,"ApprovedValues":null,"CssClass":null,"Type":{"ID":1,"Name":"DisplayText"}}
If you have any questions, please contact ISO at (800) 244-1180 or waivers@isoa.org
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