Lehigh University
Student Health Insurance Plan

UNDERGRADUATE STUDENT WAIVER FORM
2016-2017 POLICY YEAR

All undergraduate students registered for 4+ credits for the Fall 2016 semester are required to show evidence of an existing creditable health insurance policy, otherwise, they will be automatically enrolled in the university-sponsored Student Health Insurance Plan for the 2016-2017 Policy Year (8/1/16-7/31/17).

If you are an undergraduate student registered for 4+ credits and already have another health insurance plan that provides comprehensive coverage in the Lehigh area for inpatient and outpatient services in both emergency and non-emergency situations, you may opt out of the Lehigh University Student Health Insurance Plan by submitting this waiver form by the deadline.

If you do not complete a waiver or enrollment form by the deadline, you will be enrolled in the Lehigh plan and will remain responsible for the associated premium of $XXXX on your student bill.

The Waiver Deadline is September XX, 2016.
 



To continue the enrollment process, please fill out the required fields below:

~STEP 1 OF 3~

date of birth: (MM/DD/YYYY)
LIN (Lehigh Identification Number):