CLARK UNIVERSITY
STUDENT HEALTH INSURANCE PLAN

2015-16 POLICY YEAR
​ANNUAL WAIVER FORM

This form is for students enrolled in the Fall 2015 semester.


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
student ID: *
 

ID begins with the letter "C" followed by
the first eight digits of their Clark ID Card

first name: *
last name: *
last 4 digits of social security number: