St. John’s University
Student Health Insurance Plan
Resident Graduate Student 

2018-2019 Policy Year Waiver Form
(August 15, 2018 - August 14, 2019)  

In order to successfully complete the below waiver form you will need to provide your Student ID number beginning with "X". If you do not have this number, please contact St. John's University Customer Service at 718-990-2000.

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)