Stevens Institute of Technology

Student Insurance Waiver Form
2018-2019 Academic Year
 Fall Registered Graduate Students Only

TO CONTINUE THE WAIVER PROCESS, PLEASE FILL OUT THE REQUIRED FIELDS BELOW:

You must provide your 8 character Campus Wide ID (CWID) NOT your Social Security Number. If you do not know your CWID, you can retrieve it with your myStevens account by logging in at http://www.stevens.edu/mystevens and then clicking on the “SHOW MY CWID” link on the upper left hand side of the page. Please ensure the accuracy of the CWID you provide or your waiver application will not be accepted.

****Attention Undergraduates****

If you waived your health insurance through the Graduate Student link, the health insurance charge will NOT be removed from your Stevens account. If you are having difficulty logging into the Undergraduate link, please contact the Student Service Center at 201-216-5555. Health Insurance cannot be waived until it is charged to your Stevens account.

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
Campus Wide ID (CWID): *
date of birth: * (MM/DD/YYYY)

 

Student Health Plan

Optional Plans

Additional Information