CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2017-18 POLICY YEAR
ANNUAL WAIVER FORM


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
first name: *
last name: *
social security number:
student ID: * Your Clark ID number begins with "C" followed by eight digits.