St. John’s University
Student Health Insurance Plan
Resident Undergraduate Student

Spring 2019 Policy Period Waiver Form
(January 1, 2019 - August 14, 2019)

In order to successfully complete the below waiver form you will need to provide your Student ID number beginning with "X". If you do not have this number, please contact St. John's University Customer Service at 718-990-2000.

Asterisk (*) denotes required field


first name: *
last name: *
student ID: *
date of birth: * (MM/DD/YYYY)