BECKER COLLEGE
STUDENT HEALTH INSURANCE PLAN

ACCELERATED STUDENTS
2018-2019 POLICY YEAR

ANNUAL WAIVER FORM

All newly eligible Fall 2018 Accelerated students who wish to waive the Student Health Insurance Plan for the 2018-19 Policy Year must give notice of their decision by completing the Waiver Form by the deadline of November 16, 2018.

If you have any questions about the waiver process, please contact University Health Plans at 800-437-6448 or by email at info@universityhealthplans.com.


Complete the following fields to continue to the Waiver Form.

Please be sure to use the correct Student ID and Date of Birth. If they are not correct, the insurance charge will not be removed from your account.

Asterisk (*) denotes required field

STUDENT INFORMATION

 
first name: *
last name: *
student ID: * (7 digits including leading zeros)
date of birth: * (MM/DD/YYYY)