BRIDGEWATER STATE UNIVERSITY
STUDENT HEALTH PLAN
2017-2018 POLICY YEAR

Annual Plan Waiver Form

POLICY TERMS:

In order to ensure that all full time and three quarter time college students have adequate medical insurance while pursuing their academic goals, state law requires that students have coverage, either through the Bridgewater State University Student Health Plan or another United States-based carrier offering comparable coverage.

State law requires all registered students show proof of comparable coverage. If you are an undergraduate taking 9 or more credits, or a graduate student taking 7 or more credits, you will be automatically billed for the Student Health Plan on your tuition bill until proof of comparable coverage (waiver) is furnished by the deadline of September 30, 2017.

PLEASE NOTE: Health Safety Net, MassHealth Limited, and Children's Medical Security Plan cannot be used to waive the Student Health Plan. Additionally, foreign-based insurance companies and travel insurance are not allowable according to Massachusetts law.

You may enter only one decision through this system. If you have a life changing event (i.e. aging off a parent's insurance policy) and need to change your election, please contact University Health Plans at info@univhealthplans.com or 800-437-6448 to submit the appropriate forms within 60 days of the loss of coverage.


CONTINUING THE WAIVER PROCESS:

To continue the waiver process, you will need your Banner ID number which can be found on your tuition bill. This ID number is not your social security number nor your Connect Card number. Please enter your Banner ID below.

By continuing the waiver process, you are confirming that: (1) you have reviewed your current health benefits and they meet or exceed the requirements of the student health insurance plan; (2) you agree to the terms stated above; and (3) you are choosing to waive coverage in the Student Health Plan provided by Bridgewater State University, University Health Plans, and Blue Cross Blue Shield of Massachusetts.

date of birth: (MM/DD/YYYY)
Banner ID: