Lehigh University
Student Health Insurance Plan
Waiver Form

(ANNUAL) August 8, 2015 - August 7, 2016


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

Asterisk (*) denotes required field

STUDENT INFORMATION
 
LIN (Lehigh Identification Number): *
first name: *
last name: *
date of birth: * (MM/DD/YYYY)