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Risk Strategies - University Health Plans

LASELL UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

Annual Waiver Form
2024-2025 Policy Period

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

Please note that your student ID must contain 9 digits (example: 000012345)

Asterisk (*) denotes required field

 (MM/DD/YYYY)